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Keeping the “Public” in Schools of Public Health In this article, we compared the characteristics of public and private accredited public health training programs. We analyzed the distinct opportunities and challenges that publicly funded schools of public health face in preparing the nation’s public health workforce. Using our experience in creating a new, collaborative public school of public health in the nation’s largest urban public university system, we described efforts to use our public status and mission to develop new approaches to educating a workforce that meets the health needs of our region and contributes to the goal of reducing health inequalities. Finally, we considered policies that could protect and strengthen the distinct contributions that public schools of public health make to improving population health and reducing health inequalities. (Am J Public Health. 2015;105:S119–S124. doi:10. 2105/AJPH.2014.302534)
Nicholas Freudenberg, DrPH, Susan Klitzman, DrPH, Catherine Diamond, MPH, and Ayman El-Mohandes, MD, MBBCh, MPH
THE UNITED STATES HAS LONG pursued a pluralist approach to higher education, with public, private, and for-profit sectors competing for students, faculty, and funding. Professional education in public health has followed this same pattern. National debates on the affordability of higher education,1,2 its role in growing inequalities in income and wealth,3 and the implications for the composition of the future workforce entrusted to assure population health4,5 make it timely to examine the distinct roles that publicly funded universities can play. By delineating such roles, it may be possible to illuminate needed policy changes in the professional training of the nation’s public health workforce.
COMPARISON OF SCHOOLS OF PUBLIC HEALTH Of the 146 accredited public health schools and programs in the United States, 70% are publicly funded, and 30% are privately funded. Only 40% of these schools were accredited before 2000, indicating a rapid increase in both public and private schools and programs in the past 15 years. Using data from Association of Schools and Programs in Public Health annual reports,6 we compared publicly and privately funded schools and our own school, the City University of New York (CUNY) School of Public Health (SPH) on several indicators, including students, faculty, and sources of funding. We limited these analyses to accredited
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schools because data were not available for all indicators of accredited programs. Table 1 shows student characteristics at SPHs. The mean proportion of Black and Hispanic students enrolled in public schools was 29% higher (22% vs 17%) than in private schools, whereas the mean proportion of Asian students was 36% higher (15% vs 11%) at private schools than at public schools. The proportion of part-time students enrolled in public schools was almost twice as high as at private schools (24% vs 13%), whereas the proportion of international students was almost twice as high at private schools (17% vs 9%). The number of public health students in public schools represented 72% of all students in public health, as well as 82% of Hispanic students and 76% of Black students.6 The mean proportion of Black and Hispanic faculty members was 50% higher at public schools (12% vs 8%), although overall, only 10% of faculty were Black or Hispanic (Table 2).7 Faculty members at private schools were almost twice as likely to be physicians than at public schools.7 Faculty in private schools in every rank, except for tenured assistant professors, earned more than their public school colleagues.8 Student faculty ratios were more than twice as high at public schools (8.2 vs 3.4:1).6,7 Eightysix percent of public and 100% of private schools offered PhDs, whereas 63% of public and 73% of private schools offered DPHs. Half of public and 63% of private schools offered both degrees.9
As shown in Tables 1 and 3, although private schools accounted for only 22% of all schools and 28% all students, their operating budgets accounted for 46% of all SPH operating funds. Public schools had mean annual revenues of approximately 34% of private ones. Public schools relied more on university and state support (19% vs 1% of total operating funds), whereas private schools received a higher proportion of their revenues from tuition and fees (20% vs 9%). Both public and private schools received approximately one quarter of their revenue from National Institutes of Health (NIH) funding. In absolute terms, private SPHs received approximately 3 times as many NIH dollars, on average, as public SPHs, providing them with an additional stream of revenue through indirect costs. There was wide variation among individual schools in the proportion of total budget received from NIH funding, the proportion of time that faculty were expected to generate in salary support, and teaching expectations.10
OPPORTUNITIES AND CHALLENGES FOR PUBLIC SCHOOLS Compared with private schools, public ones face different opportunities and challenges. Characterizing these differences may help to identify and maximize the distinct contributions that each can make toward educating the nation’s public health workforce.
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TABLE 1—Student Demographics, US Accredited Schools of Public Health: 2013 Characteristic
Public (n = 38), No. (%); Mean
Private (n = 11), No. (%); Mean
All (n = 49), No. (%); Mean
CUNY SPH, No. (%)
8 072 (28); 212
3 030 (27); 275
11 101 (28); 227
159 (23)
20 796 (72); 547
7 994 (73); 727
28 790 (72); 588
546 (77) 64 (9)
Gender Male Female Race/ethnicity Hispanic/Latino
2 583 (10); 68
578 (6); 53
3 161 (9); 65
Asian
2 868 (11); 75
1 318 (15); 120
4 186 (12); 85
72 (10)
Black
3 252 (12); 86
1 037 (11); 94
4 289 (12); 88
135 (20)
White
14 684 (56); 386
4 931 (54); 448
19 615 (55); 400
255 (37)
Other
1 313 (5); 35
293 (3); 27
1 606 (5); 33
28 (4)
Unknown/not reported
1 616 (6); 43
968 (11); 88
2 584 (7); 53
138 (20)
Student status Part-time
6 603 (24); 174
1 323 (13); 120
7 926 (21); 162
362 (51)
Full-time
20 837 (76); 548
8 558 (87); 778
29 395 (79); 600
343 (49)
26 329 (91); 693
9 121 (83); 829
35 450 (89); 723
692 (98)
2 539 (9); 67
1 902 (17); 173
4 441 (11); 91
13 (2)
Citizenship US citizen International
Note. CUNY-SPH =City University of New York School of Public Health. Source. ASPPH Student Data Report, 2013.6
Opportunities for Publicly Funded Schools Recruit students more representative of populations carrying the heaviest burden in health disparity. Public schools enroll a higher proportion of Black and Hispanic students,
helping to achieve the benefits from a more diverse future workforce. Nevertheless, Hispanics, in particular, remain underrepresented across all SPHs, suggesting that there is a need for more targeted pipeline programs,
recruitment, and retention. Some evidence suggests that Black and Hispanic health professionals are more likely to serve in disadvantaged communities than White health professionals.11,12 Professionals who have lived in such
TABLE 2—Faculty Demographics, US Accredited Schools of Public Health: 2013 Characteristic
Public (n = 38), No. (%); Mean
Private (n = 11), No. (%); Mean
All (n = 49), No. (%); Mean
CUNY-SPH, No. (%)
Gender Male
1 695 (48); 45
1 676 (52); 152
3 371 (50); 69
19 (35)
Female
1 826 (52); 48
1 540 (48); 140
3 366 (50); 69
36 (65) 3 (5)
Race/ethnicity Hispanic/Latino
253 (7); 7
101 (3); 9
354 (5); 7
Asian
439 (12); 13
371 (12); 34
810 (12); 17
9 (16)
Black
180 (5); 5
160 (5); 15
340 (5); 7
4 (7)
White
2 573 (73); 68
2 099 (65); 191
4 672 (69); 95
39 (71)
Other
31 (0.9); < 1
8 (0.2); < 1
39 (0.6); < 1
Unknown
45 (1); 1
477 (15); 43
522 (8); 11
0 (0)
176 (9); 5 1 828 (91); 48
171 (16); 16 874 (84); 79
347 (11); 7 2 702 (89); 55
2 (4) 47 (96)
0 (0)
Physician status Physician Nonphysician
Source. ASPPH Faculty Report, 2013,7 and ASPPH Faculty Salary Report, 2013.8 Note. CUNY-SPH =City University of New York School of Public Health.
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communities may be better equipped to meet the social, cultural, and health needs of these populations.13,14 These findings suggest public schools may be making an important contribution to preparing a workforce that serves populations with greater health needs. Develop innovative forms of pedagogy. At many public schools, teaching requires a higher proportion of faculty time, whereas at many private schools, faculty devote a greater portion of time to research. This presents an opportunity for educators in public schools to take a leadership role in testing different approaches in public health education and challenging some of the established norms in the curricular structure and modes of delivery. Whether this additional effort yields greater mastery of public health competencies has not yet been empirically tested. Depend less on National Institutes of Health research funding, with its biomedical approach to population health. NIH funding provides an important source of research support and revenue (through the indirect cost returns) to public and private SPHs. To gain such support, SPHs must align their research priorities with available NIH funding, which largely focuses on biomedical rather than population health research, and in creating new knowledge rather than in translating discoveries into clinical or public health practice. At the same time, NIH funding has been shown to correlate only partially with the actual burden of disease. Some critical public health conditions (e.g., injuries, depression, and chronic obstructive pulmonary disease) are disproportionately underfunded.15 Dependence on NIH funding may force SPHs to shift their focus
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Note. CUNY = City University of New York; NIH = National Institutes of Health; SPH = Schools of Public Health. Source. ASPPH Financial Report, 2013.10 a Includes NIH funding.
1.16
$14 319 212
0.34 0.34 0.47 0.33 0.32 0.34 0.18 Means
2.78
1.16
$3 902 938 Not reported
1.86 1.14
$1 043 206 $3 902 938
1.12 1.16
$10 416 274 $6 799 635
21.12 0.50 Total
$3 599 792 CUNY-SPH
Ratio public:private
64 6 26 58 36 19 9 budget
Mean % of all SPH (n = 38; 78%)
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% of total public SPH
$1 736 644,619
$45 701 174 54 $29 175 864 54
$1 108 682,835 $109 333 457
$5 466 673 65 $12 097 984 53
$459 723 388 $999 349 378
$26 298 668 53 $16 525 310 54
$627 961 784 $333 463 068 Total Public SPHs
$150 724 673
$8 775 344 95
64 4 27 60 36 1 20 budget
% of total private SPH
$4 862 086 33
46 from this stream
$135 772 658 $86 754 801
46 35
$11 745 123 $36 784 404
46 47
$81 416 109 $49 017 857
46 5
$3 157 359 Mean (n = 11; 22%)
67
$27 552 231
Total Total Total Private SPHs
% of total SPH funding
$3 230 143,858 $1 493 499,239 $2 062 985,651 $954 302 816 $168 059 071 $58 725 614 $864 351 839 $404 628 451 $1 894 926,580 $895 577 202 $1 167 158,207 $539 196 423 $349 249 864 $15 786 796 $453 799 217 $303 074 544
Total Net Unrestricted Funds University/State Support Tuition Measure SPH Type
TABLE 3—Streams of Funding, US Accredited Schools of Public Health: 2013
Grants and Contracts Direct Costsa
NIH Funding
Other Restricted Revenue
Total Restricted Funds
Total Net Operating Funds
A RENEWED VISION FOR PUBLIC HEALTH EDUCATION
from, for example, social determinants of health or health inequities to more fundable approaches. In addition, unstable levels of funding make NIH-dependent SPHs susceptible to changing federal budget priorities. SPHs that rely more heavily on NIH funding may be more vulnerable to these limitations, requiring faculty to, as 1 researcher put it, “follow the money rather than their passions and interests, or even the logic of their research trajectory.”16 Establish partnerships with other public agencies and philanthropies. Stable funding from the state may help public schools to match their research agendas to social needs independent of the prevailing NIH funding propensities. Because public schools depend less on federal indirect cost reimbursement rates, they also have greater flexibility to pursue grants and contracts from federal, state, and local governments, as well as private philanthropies that offer lower indirect rates. With less dependence on following NIH priorities, public schools have an opportunity to develop strategies for lower costs and more sustainable research projects that capitalize on existing public and philanthropic funding streams. Develop more affordable appliedand practice-oriented research approaches. Public schools may be better able to align their research portfolios with their public service missions and to conduct research and service that contributes directly to better public health practice. Some faculty in public universities have found ways to align their research and service interests by, for example, conducting applied research, evaluation studies, or analyzing the impact of new policies on community health. More broadly, this experience may help inform a feasible
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and affordable national public health research agenda that produces the evidence needed to guide public health practice and policy. Develop more equitable partnerships with community and government organizations. Private schools are sometimes part of large academic institutions that pursue expansionary policies that create conflicts with their neighbors, especially in low-income communities. Even when public health faculty have good intentions to assist communities to realize their health goals, the residue of bad feelings from expansionist university policies and ambitions may make it difficult to engage community partners. Public universities, which have a less heavy footprint, more dependence on support from elected officials, and more access to community residents, may be better able to promote equitable partnerships. Public universities have an opportunity to demonstrate, in action, that community engagement is a priority and that they will not sacrifice community interests for their institutional goals. Demonstrate accountability to the public. A critique of higher education has been its failure to demonstrate accountability to the public.17 Public and private SPHs depend heavily on public funds. Public schools are required to demonstrate accountability to legislatures and tax payers every year, and thus, to engage in research, teaching, and services that demonstrate their relevance. They also have an opportunity to instill a sense of accountability in their graduates, who, as public health professionals, will need to be effective advocates for and defenders of public funding of health and educational programs in the future.
Play a role in educating the public about public health. Not only do SPHs educate their students and the existing public health workforce (through continuing and professional education), they also educate policymakers and the public about public health issues. Although no systematic evidence is available on the roles that public and private public health schools play in these activities, anecdotal evidence suggests that public schools have embraced this mission more fully than have private ones. For example, the majority of the Health Resources and Services Administration-funded Public Health Training Centers are based at public universities.18 Educate the workforce for the public sector. Although the role of nonprofit and for profit sectors may be growing in public health, the main responsibility for public health lies with local, state, and national government agencies. Because of their accountability to the public and their ongoing relationships with elected officials and public agencies, public schools may be better able to ensure that their graduates meet the expectations of these constituencies. Several public schools have established close relationships with city and state health departments.
Challenges for Publicly Funded Schools Public schools also face a number of challenges. They may be vulnerable to political pressures from legislatures and governors. Because public health faculty often engage in research on topics that create controversy (e.g., reproductive health, gun violence, substance abuse, and so on), elected officials may be better able to influence or discourage such research at public institutions, which depend on their support, and
research could be influenced by the prevailing ideology of elected officials. Because funding for public higher education often declines during economic downturns, publicly funded programs may lose state funding when they most need it, jeopardizing the education of some students. For example, the recent economic crisis led many states to disinvest in public universities and raise tuition,19 which reduced accessibility to graduate education in public health for students who could make important contributions to reducing health inequalities. The much higher student--faculty ratios at public universities rather than private universities and the dramatically lower per student operating cost per year ($60 212 at public and $135 451 at private schools) imposes a burden on public schools and their faculties.6,7,10 Public schools’ higher enrollment rates of Black and Hispanic and presumably low-income students may demand more resources for support, raising the question as to whether they can achieve their teaching mission with existing funding. Moreover, teaching faculty who are less involved in active research may have trouble keeping up with the latest scientific and technological developments and translating them to their students. Further empirical research is needed to ascertain how public schools can realize the opportunities and overcome the challenges they encounter. Recently, a few newly created public SPHs have documented their innovations,20---22 creating a body of evidence that can guide others. In the following, we describe our own efforts to achieve the benefits of our public status and mission to further inform more systematic investigation of the
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respective roles of public and private schools.
CASE STUDY OF A NEW PUBLIC SCHOOL OF PUBLIC HEALTH The CUNY-SPH was accredited in 2011 as a consortial school, bringing together several previously accredited programs in public health. As shown in Table 1, our school enrolls proportionally more Black and Hispanic students and more part-time students than the average public or private SPH.6 CUNY’s local workforce development mission and lower tuition rates for state residents result in a student body that reflects the diverse urban metropolitan population. CUNY-SPH seeks to attract students from less privileged backgrounds by offering classes after work hours and accepting full- and part-time students. Recent surveys showed that 75% to 80% of our students work while attending school.23 The CUNY-SPH encourages intensive faculty interactions with students, inside and outside the classroom. Students who are first in their family to attend college and graduate school often lack mentors and coaches in their immediate circles and may need assistance in negotiating competing demands. To ensure that CUNY graduates contribute directly to New York City, the school chose to make improving the health of urban populations a core feature of its curriculum. Several courses and most field work placements emphasize the application of public health theories and methods in urban settings. A 2013 alumni survey found that the top employment sectors among SPH graduates were health care (37%), local government (21%), and
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nonprofit organizations (21%) in the metropolitan region.23 To ensure that faculty have the skills needed to prepare students for practice, CUNY-SPH hires faculty with previous practice experience. To reinforce the value of practice, CUNY-SPH developed tenure and promotion guidelines that reflect its values on teaching, applied research, and service, such as including scholarly publications based on evaluation of professional practice and a definition of service that includes service to community organizations. CUNY-SPH faculty have become adept at developing low-cost research. Among these strategies are acquiring public databases to conduct more in depth analysis than municipal agencies are able to undertake, developing partnerships with organizations that can pay for student researchers and faculty time, and serving as coinvestigators with researchers at more research intensive universities. CUNY-SPH has also developed close partnerships with city agencies and community organizations. With more than 635 placements at 290 sites, the SPH has created an internship program that includes placements in every niche of the public health landscape. This diversity of placements allows students to pursue special interests and gain relevant professional experience. Finally, to contribute to the region’s overall health, CUNY-SPH has developed new programs to promote the health of CUNY’s 270 000 degree students and 263 000 nondegree students, and to prepare some to bring health messages and resources to their peers, families, and communities.24 To ensure that its graduates can meet the future public health workforce needs of the region, CUNY has convened faculty and
administrators from 15 CUNY community and senior colleges that offer degrees related to public health to plan multiple pathways that will allow CUNY students to advance from associates’ to bachelor’s, master’s, and doctoral degrees in public health. As public health turns its attention to community college and undergraduate preparation for careers in public health,25,26 CUNY has the opportunity to create a single integrated multilevel system for producing the workforce needed to maintain and improve regional population health. The previously highlighted features of the CUNY-SPH can also be found in other public and private SPHs. Our argument is that organizational and structural factors associated with its public status make institutional choices that promote population health easier choices. However, many of these characteristics pose significant economic, political, and academic challenges. Public universities operate in a tight fiscal climate, in which the proportion of overall operating expenses derived from tuition nationally has been steadily increasing—from 20% in 1987 to 44% in 2012.27 Since the economic recession of 2008, many state legislators have been unwilling or unable to restore public funding levels.28 In this environment, universities often face financial and political pressure to continue to raise tuition, thereby inadvertently imposing hardships on students with fewer economic reserves. Although the number of students enrolled in SPHs has steadily increased, future trends are unclear, because of the increase in the number of new schools and programs and nationally declining graduate enrollments.29 Meeting Council on Education for Public
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Health required graduation rates of 70% is challenging with a parttime student body with competing work and family demands. In addition, public SPHs lack the extensive academic support services of most private universities. Some of our choices (catering to part-time working students, focusing on community-oriented practice and service) may be in conflict with the external demands of accrediting bodies, philanthropists, and foundations, which are often hesitant to contribute to public versus private research intensive institutions. Although faculty and administrators in universities with a strong public mandate may cherish these distinctions, in the “real world” they may serve as handicaps for traditional measures of success (e.g., high graduation rates and external funding).
IMPLICATIONS FOR PUBLIC POLICY In the United States, public SPHs represent the majority of all SPHs and public health students. However, the public and private sectors play different roles and make different contributions to the mission of improving population health and reducing health inequalities, which are 2 core goals of public health. At present, compared with private universities, public universities educate and hire more Blacks and Hispanics as faculty, enroll more part-time students, engage more with local and state governments, and are more directly accountable to the public. Public and private SPHs differ in other ways: private universities spend more than twice as much in net operating costs per student per year and receive, on average, 3 times the mean dollar value of NIH funding as public schools.
A significant percentage of this higher spending of public dollars goes to the development of infrastructure and the support of higher faculty salaries. This disproportionate spending and funding shifts public dollars and the generous overhead costs they support to a potentially less cost efficient and more expensive private sector. The economic stability of this sector is becoming more and more dependent on externally funded research and less on developing the workforce needed to achieve national health goals. In the long run, this path seems unsustainable. In the future, policymakers should find ways to ensure that public spending on public health training makes achieving public goals, such as improving population health and reducing health inequalities, a higher priority. Private institutions should be expected to channel privately raised funds and higher tuition revenues toward sustaining their own self-defined goals, and become directly accountable in how their spending of public funds is aligned with public priorities. To ensure that public health workforce development policies contribute to these goals, policymakers, public health officials, and educators should develop policies that enable public SPHs to capitalize on their capacity to educate a more diverse public health work force, reduce training costs, translate knowledge into practice, engage communities and governments in public health, promote health-in-all-policies, and become more accountable to the public. j
About the Authors All of the authors are with the City University of New York School of Public Health, New York, NY. Nicholas Freudenberg is also with Hunter College, City University of New York.
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Correspondence should be sent to Nicholas Freudenberg, City University of New York School of Public Health, Silberman Building, 2180 Third Avenue, New York, NY 10035 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph. org by clicking the “Reprints” link. This article was accepted December 24, 2014.
Contributors All of the authors contributed to conceptualization, data analysis, writing, and editorial revisions.
Acknowledgments We acknowledge the contributions of CUNY School of Public Health students, faculty and administrators in defining the school’s mission and activities. We also thank the CUNY Chancellor’s Office and the Presidents and Provosts of Brooklyn, Hunter, and Lehman Colleges and the CUNY Graduate Center for their continuing support for the public mission of the School of Public Health.
Human Participant Protection Institutional review board approval was not required because the study did not involve human participants.
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Schools and Programs of Public Health; 2013. 9. Association of Schools and Programs of Public Health. Academic Program Finder. 2014. Available at: http://www. aspph.org/program-finder. Accessed September 5, 2014. 10. Association of Schools and Programs of Public Health. ASPPH Financial Report. Washington, DC: Association of Schools and Programs of Public Health; 2013. 11. Komaromy M, Grumbach K, Drake M, et al. The role of Black and Hispanic physicians in providing health care for underserved populations. N Engl J Med. 1996;334(20):1305---1310. 12. Cohen JJ, Gabriel BA, Terrell C. The case for diversity in the health care workforce. Health Aff (Millwood). 2002;21(5): 90---102. 13. Grumbach K, Mendoza R. Disparities in human resources: addressing the lack of diversity in the health professions. Health Aff (Millwood). 2008;27(2): 413---422. 14. Annang L, Richter DL, Fletcher FE, Weis MA, Fernandes PR, Clary LA. Diversifying the academic public health workforce: strategies to extend the discourse about limited racial and ethnic diversity in the public health academy. ABNF J. 2010;21(2):39---43. 15. Gillum LA, Gouveia C, Dorsey ER, et al. NIH disease funding levels and burden of disease. PLoS ONE. 2011;6(2): e16837---16839. 16. Stein DG, Candler AG. Hard Money/ Soft Money: The Two Cultures. Available at: http://www.emory.edu/ACAD_ EXCHANGE/2007/may/steinessay. html. Accessed June 18, 2014. 17. Leveille DE. Accountability in Higher Education: A Public Agenda for Trust and Cultural Change. Center for Studies in Higher Education, University of California Berkeley; 2007. Available at: http://files.eric.ed.gov/fulltext/ ED503070.pdf. Accessed June 18, 2014. 18. Health Resources and Services Administration. About Public Health Training Centers. Available at: http://bhpr.hrsa.gov/ grants/publichealth/trainingcenters/about/ index.html. Accessed June 18, 2014.
21. Kreuter MW, Kegler MC, Joseph KT, Redwood YA, Hooker M. The impact of implementing selected CBPR strategies to address disparities in urban Atlanta: a retrospective case study. Health Educ Res. 2012;27(4):729---741. 22. Childs K, Frick P. University Partnerships as a Strategy for Promoting Data-Driven Decision Making in Juvenile Justice. Innovation Brief, 2013. Available at: http://sph.lsuhsc.edu/Websites/ lsupublichealth/images/pdf/iphj/ LA_Univ__Partnership__Inno_Brief_ 2013.pdf. Accessed June 18, 2014. 23. City University of New York School of Public Health. 2013 Annual Report to CEPH. New York, NY: City University of New York of Public Health; 2013. 24. Freudenberg N, Manzo L, Mongiello L, Jones H, Boeri N, Lamberson P. Promoting the health of young adults in urban public universities: a case study from City University of New York. J Am Coll Health. 2013;61(7):422---430. 25. Riegelman RK, Albertine S. Undergraduate public health at 4-year institutions: it’s here to stay. Am J Prev Med. 2011;40(2):226---231. 26. Kirkwood BA, Riegelman RK. Community colleges and public health: making the connections. Am J Prev Med. 2011;40 (2):220---225. 27. State Higher Education Executive Officers Association. SHEF—State Higher Education Finance FY12. 2012. Available at: http://www.sheeo.org/node/ 631. Accessed June 19, 2014. 28. Hiltonsmith R, Draut T. The Great Cost Shift Continues: State Higher Education Funding After the Recession. DEMOS. 2014. Available at: www. demos.org/publication/great-cost-shiftcontinues-state-higher-education-fundingafter-recession. Accessed June 18, 2014. 29. Rampell C. Enrollment Drops Again in Graduate Programs. NY Times, Business Day. 2012. Available at: www. nytimes.com/2012/09/28/business/ new-enrollment-drops-again-in-usgraduate-schools.html?_r=0. Accessed June 19, 2014.
19. Hartman J, Kileff H, McElligott JE, Stephens MA. Trends in Higher Education and Schools of Public Health. Washington, DC: Association of Schools of Public Health; 2011. 20. Imperato PJ, LaRosa JH, Kavaler F, Benker K, Schechter L. The establishment of the School of Public Health at the State University of New York Downstate Medical Center: the first nationally accredited school of public health in a public university in New York City. J Community Health. 2011;36(1):1---13.
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American Journal of Public Health | Supplement 1, 2015, Vol 105, No. S1
Keeping the “Public” in Schools of Public Health In this article, we compared the characteristics of public and private accredited public health training programs. We analyzed the distinct opportunities and challenges that publicly funded schools of public health face in preparing the nation’s public health workforce. Using our experience in creating a new, collaborative public school of public health in the nation’s largest urban public university system, we described efforts to use our public status and mission to develop new approaches to educating a workforce that meets the health needs of our region and contributes to the goal of reducing health inequalities. Finally, we considered policies that could protect and strengthen the distinct contributions that public schools of public health make to improving population health and reducing health inequalities. (Am J Public Health. 2015;105:S119–S124. doi:10. 2105/AJPH.2014.302534)
Nicholas Freudenberg, DrPH, Susan Klitzman, DrPH, Catherine Diamond, MPH, and Ayman El-Mohandes, MD, MBBCh, MPH
THE UNITED STATES HAS LONG pursued a pluralist approach to higher education, with public, private, and for-profit sectors competing for students, faculty, and funding. Professional education in public health has followed this same pattern. National debates on the affordability of higher education,1,2 its role in growing inequalities in income and wealth,3 and the implications for the composition of the future workforce entrusted to assure population health4,5 make it timely to examine the distinct roles that publicly funded universities can play. By delineating such roles, it may be possible to illuminate needed policy changes in the professional training of the nation’s public health workforce.
COMPARISON OF SCHOOLS OF PUBLIC HEALTH Of the 146 accredited public health schools and programs in the United States, 70% are publicly funded, and 30% are privately funded. Only 40% of these schools were accredited before 2000, indicating a rapid increase in both public and private schools and programs in the past 15 years. Using data from Association of Schools and Programs in Public Health annual reports,6 we compared publicly and privately funded schools and our own school, the City University of New York (CUNY) School of Public Health (SPH) on several indicators, including students, faculty, and sources of funding. We limited these analyses to accredited
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schools because data were not available for all indicators of accredited programs. Table 1 shows student characteristics at SPHs. The mean proportion of Black and Hispanic students enrolled in public schools was 29% higher (22% vs 17%) than in private schools, whereas the mean proportion of Asian students was 36% higher (15% vs 11%) at private schools than at public schools. The proportion of part-time students enrolled in public schools was almost twice as high as at private schools (24% vs 13%), whereas the proportion of international students was almost twice as high at private schools (17% vs 9%). The number of public health students in public schools represented 72% of all students in public health, as well as 82% of Hispanic students and 76% of Black students.6 The mean proportion of Black and Hispanic faculty members was 50% higher at public schools (12% vs 8%), although overall, only 10% of faculty were Black or Hispanic (Table 2).7 Faculty members at private schools were almost twice as likely to be physicians than at public schools.7 Faculty in private schools in every rank, except for tenured assistant professors, earned more than their public school colleagues.8 Student faculty ratios were more than twice as high at public schools (8.2 vs 3.4:1).6,7 Eightysix percent of public and 100% of private schools offered PhDs, whereas 63% of public and 73% of private schools offered DPHs. Half of public and 63% of private schools offered both degrees.9
As shown in Tables 1 and 3, although private schools accounted for only 22% of all schools and 28% all students, their operating budgets accounted for 46% of all SPH operating funds. Public schools had mean annual revenues of approximately 34% of private ones. Public schools relied more on university and state support (19% vs 1% of total operating funds), whereas private schools received a higher proportion of their revenues from tuition and fees (20% vs 9%). Both public and private schools received approximately one quarter of their revenue from National Institutes of Health (NIH) funding. In absolute terms, private SPHs received approximately 3 times as many NIH dollars, on average, as public SPHs, providing them with an additional stream of revenue through indirect costs. There was wide variation among individual schools in the proportion of total budget received from NIH funding, the proportion of time that faculty were expected to generate in salary support, and teaching expectations.10
OPPORTUNITIES AND CHALLENGES FOR PUBLIC SCHOOLS Compared with private schools, public ones face different opportunities and challenges. Characterizing these differences may help to identify and maximize the distinct contributions that each can make toward educating the nation’s public health workforce.
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TABLE 1—Student Demographics, US Accredited Schools of Public Health: 2013 Characteristic
Public (n = 38), No. (%); Mean
Private (n = 11), No. (%); Mean
All (n = 49), No. (%); Mean
CUNY SPH, No. (%)
8 072 (28); 212
3 030 (27); 275
11 101 (28); 227
159 (23)
20 796 (72); 547
7 994 (73); 727
28 790 (72); 588
546 (77) 64 (9)
Gender Male Female Race/ethnicity Hispanic/Latino
2 583 (10); 68
578 (6); 53
3 161 (9); 65
Asian
2 868 (11); 75
1 318 (15); 120
4 186 (12); 85
72 (10)
Black
3 252 (12); 86
1 037 (11); 94
4 289 (12); 88
135 (20)
White
14 684 (56); 386
4 931 (54); 448
19 615 (55); 400
255 (37)
Other
1 313 (5); 35
293 (3); 27
1 606 (5); 33
28 (4)
Unknown/not reported
1 616 (6); 43
968 (11); 88
2 584 (7); 53
138 (20)
Student status Part-time
6 603 (24); 174
1 323 (13); 120
7 926 (21); 162
362 (51)
Full-time
20 837 (76); 548
8 558 (87); 778
29 395 (79); 600
343 (49)
26 329 (91); 693
9 121 (83); 829
35 450 (89); 723
692 (98)
2 539 (9); 67
1 902 (17); 173
4 441 (11); 91
13 (2)
Citizenship US citizen International
Note. CUNY-SPH =City University of New York School of Public Health. Source. ASPPH Student Data Report, 2013.6
Opportunities for Publicly Funded Schools Recruit students more representative of populations carrying the heaviest burden in health disparity. Public schools enroll a higher proportion of Black and Hispanic students,
helping to achieve the benefits from a more diverse future workforce. Nevertheless, Hispanics, in particular, remain underrepresented across all SPHs, suggesting that there is a need for more targeted pipeline programs,
recruitment, and retention. Some evidence suggests that Black and Hispanic health professionals are more likely to serve in disadvantaged communities than White health professionals.11,12 Professionals who have lived in such
TABLE 2—Faculty Demographics, US Accredited Schools of Public Health: 2013 Characteristic
Public (n = 38), No. (%); Mean
Private (n = 11), No. (%); Mean
All (n = 49), No. (%); Mean
CUNY-SPH, No. (%)
Gender Male
1 695 (48); 45
1 676 (52); 152
3 371 (50); 69
19 (35)
Female
1 826 (52); 48
1 540 (48); 140
3 366 (50); 69
36 (65) 3 (5)
Race/ethnicity Hispanic/Latino
253 (7); 7
101 (3); 9
354 (5); 7
Asian
439 (12); 13
371 (12); 34
810 (12); 17
9 (16)
Black
180 (5); 5
160 (5); 15
340 (5); 7
4 (7)
White
2 573 (73); 68
2 099 (65); 191
4 672 (69); 95
39 (71)
Other
31 (0.9); < 1
8 (0.2); < 1
39 (0.6); < 1
Unknown
45 (1); 1
477 (15); 43
522 (8); 11
0 (0)
176 (9); 5 1 828 (91); 48
171 (16); 16 874 (84); 79
347 (11); 7 2 702 (89); 55
2 (4) 47 (96)
0 (0)
Physician status Physician Nonphysician
Source. ASPPH Faculty Report, 2013,7 and ASPPH Faculty Salary Report, 2013.8 Note. CUNY-SPH =City University of New York School of Public Health.
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communities may be better equipped to meet the social, cultural, and health needs of these populations.13,14 These findings suggest public schools may be making an important contribution to preparing a workforce that serves populations with greater health needs. Develop innovative forms of pedagogy. At many public schools, teaching requires a higher proportion of faculty time, whereas at many private schools, faculty devote a greater portion of time to research. This presents an opportunity for educators in public schools to take a leadership role in testing different approaches in public health education and challenging some of the established norms in the curricular structure and modes of delivery. Whether this additional effort yields greater mastery of public health competencies has not yet been empirically tested. Depend less on National Institutes of Health research funding, with its biomedical approach to population health. NIH funding provides an important source of research support and revenue (through the indirect cost returns) to public and private SPHs. To gain such support, SPHs must align their research priorities with available NIH funding, which largely focuses on biomedical rather than population health research, and in creating new knowledge rather than in translating discoveries into clinical or public health practice. At the same time, NIH funding has been shown to correlate only partially with the actual burden of disease. Some critical public health conditions (e.g., injuries, depression, and chronic obstructive pulmonary disease) are disproportionately underfunded.15 Dependence on NIH funding may force SPHs to shift their focus
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Note. CUNY = City University of New York; NIH = National Institutes of Health; SPH = Schools of Public Health. Source. ASPPH Financial Report, 2013.10 a Includes NIH funding.
1.16
$14 319 212
0.34 0.34 0.47 0.33 0.32 0.34 0.18 Means
2.78
1.16
$3 902 938 Not reported
1.86 1.14
$1 043 206 $3 902 938
1.12 1.16
$10 416 274 $6 799 635
21.12 0.50 Total
$3 599 792 CUNY-SPH
Ratio public:private
64 6 26 58 36 19 9 budget
Mean % of all SPH (n = 38; 78%)
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% of total public SPH
$1 736 644,619
$45 701 174 54 $29 175 864 54
$1 108 682,835 $109 333 457
$5 466 673 65 $12 097 984 53
$459 723 388 $999 349 378
$26 298 668 53 $16 525 310 54
$627 961 784 $333 463 068 Total Public SPHs
$150 724 673
$8 775 344 95
64 4 27 60 36 1 20 budget
% of total private SPH
$4 862 086 33
46 from this stream
$135 772 658 $86 754 801
46 35
$11 745 123 $36 784 404
46 47
$81 416 109 $49 017 857
46 5
$3 157 359 Mean (n = 11; 22%)
67
$27 552 231
Total Total Total Private SPHs
% of total SPH funding
$3 230 143,858 $1 493 499,239 $2 062 985,651 $954 302 816 $168 059 071 $58 725 614 $864 351 839 $404 628 451 $1 894 926,580 $895 577 202 $1 167 158,207 $539 196 423 $349 249 864 $15 786 796 $453 799 217 $303 074 544
Total Net Unrestricted Funds University/State Support Tuition Measure SPH Type
TABLE 3—Streams of Funding, US Accredited Schools of Public Health: 2013
Grants and Contracts Direct Costsa
NIH Funding
Other Restricted Revenue
Total Restricted Funds
Total Net Operating Funds
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from, for example, social determinants of health or health inequities to more fundable approaches. In addition, unstable levels of funding make NIH-dependent SPHs susceptible to changing federal budget priorities. SPHs that rely more heavily on NIH funding may be more vulnerable to these limitations, requiring faculty to, as 1 researcher put it, “follow the money rather than their passions and interests, or even the logic of their research trajectory.”16 Establish partnerships with other public agencies and philanthropies. Stable funding from the state may help public schools to match their research agendas to social needs independent of the prevailing NIH funding propensities. Because public schools depend less on federal indirect cost reimbursement rates, they also have greater flexibility to pursue grants and contracts from federal, state, and local governments, as well as private philanthropies that offer lower indirect rates. With less dependence on following NIH priorities, public schools have an opportunity to develop strategies for lower costs and more sustainable research projects that capitalize on existing public and philanthropic funding streams. Develop more affordable appliedand practice-oriented research approaches. Public schools may be better able to align their research portfolios with their public service missions and to conduct research and service that contributes directly to better public health practice. Some faculty in public universities have found ways to align their research and service interests by, for example, conducting applied research, evaluation studies, or analyzing the impact of new policies on community health. More broadly, this experience may help inform a feasible
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and affordable national public health research agenda that produces the evidence needed to guide public health practice and policy. Develop more equitable partnerships with community and government organizations. Private schools are sometimes part of large academic institutions that pursue expansionary policies that create conflicts with their neighbors, especially in low-income communities. Even when public health faculty have good intentions to assist communities to realize their health goals, the residue of bad feelings from expansionist university policies and ambitions may make it difficult to engage community partners. Public universities, which have a less heavy footprint, more dependence on support from elected officials, and more access to community residents, may be better able to promote equitable partnerships. Public universities have an opportunity to demonstrate, in action, that community engagement is a priority and that they will not sacrifice community interests for their institutional goals. Demonstrate accountability to the public. A critique of higher education has been its failure to demonstrate accountability to the public.17 Public and private SPHs depend heavily on public funds. Public schools are required to demonstrate accountability to legislatures and tax payers every year, and thus, to engage in research, teaching, and services that demonstrate their relevance. They also have an opportunity to instill a sense of accountability in their graduates, who, as public health professionals, will need to be effective advocates for and defenders of public funding of health and educational programs in the future.
Play a role in educating the public about public health. Not only do SPHs educate their students and the existing public health workforce (through continuing and professional education), they also educate policymakers and the public about public health issues. Although no systematic evidence is available on the roles that public and private public health schools play in these activities, anecdotal evidence suggests that public schools have embraced this mission more fully than have private ones. For example, the majority of the Health Resources and Services Administration-funded Public Health Training Centers are based at public universities.18 Educate the workforce for the public sector. Although the role of nonprofit and for profit sectors may be growing in public health, the main responsibility for public health lies with local, state, and national government agencies. Because of their accountability to the public and their ongoing relationships with elected officials and public agencies, public schools may be better able to ensure that their graduates meet the expectations of these constituencies. Several public schools have established close relationships with city and state health departments.
Challenges for Publicly Funded Schools Public schools also face a number of challenges. They may be vulnerable to political pressures from legislatures and governors. Because public health faculty often engage in research on topics that create controversy (e.g., reproductive health, gun violence, substance abuse, and so on), elected officials may be better able to influence or discourage such research at public institutions, which depend on their support, and
research could be influenced by the prevailing ideology of elected officials. Because funding for public higher education often declines during economic downturns, publicly funded programs may lose state funding when they most need it, jeopardizing the education of some students. For example, the recent economic crisis led many states to disinvest in public universities and raise tuition,19 which reduced accessibility to graduate education in public health for students who could make important contributions to reducing health inequalities. The much higher student--faculty ratios at public universities rather than private universities and the dramatically lower per student operating cost per year ($60 212 at public and $135 451 at private schools) imposes a burden on public schools and their faculties.6,7,10 Public schools’ higher enrollment rates of Black and Hispanic and presumably low-income students may demand more resources for support, raising the question as to whether they can achieve their teaching mission with existing funding. Moreover, teaching faculty who are less involved in active research may have trouble keeping up with the latest scientific and technological developments and translating them to their students. Further empirical research is needed to ascertain how public schools can realize the opportunities and overcome the challenges they encounter. Recently, a few newly created public SPHs have documented their innovations,20---22 creating a body of evidence that can guide others. In the following, we describe our own efforts to achieve the benefits of our public status and mission to further inform more systematic investigation of the
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respective roles of public and private schools.
CASE STUDY OF A NEW PUBLIC SCHOOL OF PUBLIC HEALTH The CUNY-SPH was accredited in 2011 as a consortial school, bringing together several previously accredited programs in public health. As shown in Table 1, our school enrolls proportionally more Black and Hispanic students and more part-time students than the average public or private SPH.6 CUNY’s local workforce development mission and lower tuition rates for state residents result in a student body that reflects the diverse urban metropolitan population. CUNY-SPH seeks to attract students from less privileged backgrounds by offering classes after work hours and accepting full- and part-time students. Recent surveys showed that 75% to 80% of our students work while attending school.23 The CUNY-SPH encourages intensive faculty interactions with students, inside and outside the classroom. Students who are first in their family to attend college and graduate school often lack mentors and coaches in their immediate circles and may need assistance in negotiating competing demands. To ensure that CUNY graduates contribute directly to New York City, the school chose to make improving the health of urban populations a core feature of its curriculum. Several courses and most field work placements emphasize the application of public health theories and methods in urban settings. A 2013 alumni survey found that the top employment sectors among SPH graduates were health care (37%), local government (21%), and
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nonprofit organizations (21%) in the metropolitan region.23 To ensure that faculty have the skills needed to prepare students for practice, CUNY-SPH hires faculty with previous practice experience. To reinforce the value of practice, CUNY-SPH developed tenure and promotion guidelines that reflect its values on teaching, applied research, and service, such as including scholarly publications based on evaluation of professional practice and a definition of service that includes service to community organizations. CUNY-SPH faculty have become adept at developing low-cost research. Among these strategies are acquiring public databases to conduct more in depth analysis than municipal agencies are able to undertake, developing partnerships with organizations that can pay for student researchers and faculty time, and serving as coinvestigators with researchers at more research intensive universities. CUNY-SPH has also developed close partnerships with city agencies and community organizations. With more than 635 placements at 290 sites, the SPH has created an internship program that includes placements in every niche of the public health landscape. This diversity of placements allows students to pursue special interests and gain relevant professional experience. Finally, to contribute to the region’s overall health, CUNY-SPH has developed new programs to promote the health of CUNY’s 270 000 degree students and 263 000 nondegree students, and to prepare some to bring health messages and resources to their peers, families, and communities.24 To ensure that its graduates can meet the future public health workforce needs of the region, CUNY has convened faculty and
administrators from 15 CUNY community and senior colleges that offer degrees related to public health to plan multiple pathways that will allow CUNY students to advance from associates’ to bachelor’s, master’s, and doctoral degrees in public health. As public health turns its attention to community college and undergraduate preparation for careers in public health,25,26 CUNY has the opportunity to create a single integrated multilevel system for producing the workforce needed to maintain and improve regional population health. The previously highlighted features of the CUNY-SPH can also be found in other public and private SPHs. Our argument is that organizational and structural factors associated with its public status make institutional choices that promote population health easier choices. However, many of these characteristics pose significant economic, political, and academic challenges. Public universities operate in a tight fiscal climate, in which the proportion of overall operating expenses derived from tuition nationally has been steadily increasing—from 20% in 1987 to 44% in 2012.27 Since the economic recession of 2008, many state legislators have been unwilling or unable to restore public funding levels.28 In this environment, universities often face financial and political pressure to continue to raise tuition, thereby inadvertently imposing hardships on students with fewer economic reserves. Although the number of students enrolled in SPHs has steadily increased, future trends are unclear, because of the increase in the number of new schools and programs and nationally declining graduate enrollments.29 Meeting Council on Education for Public
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Health required graduation rates of 70% is challenging with a parttime student body with competing work and family demands. In addition, public SPHs lack the extensive academic support services of most private universities. Some of our choices (catering to part-time working students, focusing on community-oriented practice and service) may be in conflict with the external demands of accrediting bodies, philanthropists, and foundations, which are often hesitant to contribute to public versus private research intensive institutions. Although faculty and administrators in universities with a strong public mandate may cherish these distinctions, in the “real world” they may serve as handicaps for traditional measures of success (e.g., high graduation rates and external funding).
IMPLICATIONS FOR PUBLIC POLICY In the United States, public SPHs represent the majority of all SPHs and public health students. However, the public and private sectors play different roles and make different contributions to the mission of improving population health and reducing health inequalities, which are 2 core goals of public health. At present, compared with private universities, public universities educate and hire more Blacks and Hispanics as faculty, enroll more part-time students, engage more with local and state governments, and are more directly accountable to the public. Public and private SPHs differ in other ways: private universities spend more than twice as much in net operating costs per student per year and receive, on average, 3 times the mean dollar value of NIH funding as public schools.
A significant percentage of this higher spending of public dollars goes to the development of infrastructure and the support of higher faculty salaries. This disproportionate spending and funding shifts public dollars and the generous overhead costs they support to a potentially less cost efficient and more expensive private sector. The economic stability of this sector is becoming more and more dependent on externally funded research and less on developing the workforce needed to achieve national health goals. In the long run, this path seems unsustainable. In the future, policymakers should find ways to ensure that public spending on public health training makes achieving public goals, such as improving population health and reducing health inequalities, a higher priority. Private institutions should be expected to channel privately raised funds and higher tuition revenues toward sustaining their own self-defined goals, and become directly accountable in how their spending of public funds is aligned with public priorities. To ensure that public health workforce development policies contribute to these goals, policymakers, public health officials, and educators should develop policies that enable public SPHs to capitalize on their capacity to educate a more diverse public health work force, reduce training costs, translate knowledge into practice, engage communities and governments in public health, promote health-in-all-policies, and become more accountable to the public. j
About the Authors All of the authors are with the City University of New York School of Public Health, New York, NY. Nicholas Freudenberg is also with Hunter College, City University of New York.
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Correspondence should be sent to Nicholas Freudenberg, City University of New York School of Public Health, Silberman Building, 2180 Third Avenue, New York, NY 10035 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph. org by clicking the “Reprints” link. This article was accepted December 24, 2014.
Contributors All of the authors contributed to conceptualization, data analysis, writing, and editorial revisions.
Acknowledgments We acknowledge the contributions of CUNY School of Public Health students, faculty and administrators in defining the school’s mission and activities. We also thank the CUNY Chancellor’s Office and the Presidents and Provosts of Brooklyn, Hunter, and Lehman Colleges and the CUNY Graduate Center for their continuing support for the public mission of the School of Public Health.
Human Participant Protection Institutional review board approval was not required because the study did not involve human participants.
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