Understanding public health professionals: their roles, significance, and challenges

The dramatic progress in public health throughout the 20th century, including the extension of life expectancy, enhancement of quality of life, and significant reductions in infant and child mortality rates, as well as the successful reduction and eradication of some infectious diseases, could not have been achieved without public health professionals responsible for the management, coordination, and provision of essential public health services. Public health systems in countries around the world, including the Republic of Serbia, are “chronically” underinvested, and face difficulties in ensuring an adequate number and appropriate distribution of qualified public health workers. Numerous challenges related to the public health workforce can be classified into several groups: social (aging workers, the profession’s lack of appeal, diminished morale and motivation, retention challenges); technological (the diverse array of education and training options, scarce opportunities for professional development); economic (insufficient financing and low salaries); environmental (antibiotic resistance, pollution, food safety, climate change, urbanization); political (lack of prominence on the agendas of political leaders, lack of legal frameworks for workforce development); and legal and ethical (absence of a well-defined ethical framework in public health). To deliver high-quality public health services, mitigate health disparities, and effectively tackle emerging health crises, enhancing the capabilities of a skilled and competent workforce is imperative. This involves gaining a comprehensive understanding of the interests and needs of public health professionals, implementing strategic succession planning, optimizing recruitment and retention of workers, and ensuring more efficient use of resources. A thorough examination of public health personnel management, together with the development of strategic and operational personnel policies within the healthcare system of the Republic of Serbia, is necessary for effectively addressing the demands posed by crises such as the outbreak of a novel infectious disease pandemic.

INTRODUCTION

Public health

Although the principles and practices of public health have been acknowledged and utilized for centuries, the origin of the discipline traces back to the end of the 19th century and the era of the industrial revolution. Following the initial phase related to the development of scientific and practical aspects of public health and enhancing hygienic and sanitary conditions, the evolution of public health entered subsequent stages. This transition included focus on individual healthcare, followed by the integration of therapeutic interventions, which led to a reorganization in public health institutions with a focus on community engagement, health education, and participation in international public health activities. In the latter half of the 20th century, a new era of public health emerged, based on a holistic approach to health. This approach aimed at systematically identifying health needs, enhancing health and quality of life, preventing diseases, and structuring health services to deliver comprehensive, high-quality care tailored to specific populations [1].

During the entire century of efforts to define public health, a single definition that fully reflects the complexity of this field has remained elusive [2]. In literature, Acheson’s definition, which has also been acknowledged by the World Health Organization (WHO) as a valuable starting point for exploring public health, is most often cited. According to this definition, public health is the science and art of preventing disease, prolonging life and promoting health through the organized efforts of society" [3]. However, considering the ever-changing nature of public health challenges, coupled with the realization that the most recent original definitions of public health were formulated nearly 20 years ago, it becomes imperative to undertake a comprehensive review and revision of these definitions [2].

PUBLIC HEALTH PROFESSIONALS

Public health requires a strong and sustainable workforce, comprising a sufficient number of educated, skilled and motivated multidisciplinary public health professionals capable of providing high-quality public health services [4].

There is no universally recognized and widely accepted definition of the public health workforce. Rotem et al., in their definition of the public health workforce as “persons who are involved in the protection, promotion and/or restoration of the collective health of the entire or certain population (as opposed to activities aimed at caring for individuals)” [5] underscored the scope of public health workers’ endeavors, emphasizing the distinction between public health and clinical practice. Beaglehole and Dal Poz’s definition highlights the multidisciplinary nature of the public health workforce. They describe it as a diverse workforce whose primary responsibility is to provide key public health activities, regardless of their organizational basis [6]. The definition of the American Institute of Medicine states that the public health workforce consists of individuals educated in the field of public health or a related discipline who are employed to improve health by focusing on the population [7], emphasizing the significance of formal education and evidence-based approaches in public health interventions. Building upon Whitfield’s framework [8], the European Action Plan for Strengthening Public Health Capacity and Services recognizes three distinct groups within the public health workforce. These include public health specialists who constitute the nucleus of the workforce (epidemiologists, health promotion specialists, and biostatisticians), healthcare professionals who, while not exclusively tasked with public health roles, deliver health promotion and disease prevention services (general practitioners, nurses, pharmacists, social workers, and psychologists), and professionals outside the health sector whose decisions and activities impact public health (government officials involved in urban planning, education, transportation, etc.) [9]. This comprehensive approach to defining the public health workforce remains relevant today [10].

In a recent systematic literature review, Watts et al. categorized definitions of the public health workforce into pragmatic and conceptual frameworks. Pragmatic definitions delineate public health workers based on their employer, the functions they fulfill, their occupational roles, or their training. On the other hand, conceptual definitions primarily emphasize the focus of public health workers’ activities on enhancing the health of entire populations. These authors advocate for the pragmatic definition of the public health workforce, which identifies individuals based on their roles and functions. According to this perspective, public health workers are defined as individuals engaged in executing specific public health functions [11].

ESSENTIAL PUBLIC HEALTH FUNCTIONS

Toward the end of the twentieth century, amidst rapid transformations in health, demographics, society, and politics around the world, the notion of essential public health functions emerged. This concept aimed at establishing an optimal framework for the operation of public health systems, effectively addressing emergent and pressing public health challenges [12]. In 1988, the American Institute of Medicine defined three fundamental functions to encapsulate the scope of public health services and responsibilities: evaluating population health and discerning health priorities, formulating policies to tackle national health issues and priorities, and guaranteeing access to sufficient healthcare [13]. These functions served as the basis for establishing the scope of work for essential public health services in the United States of America (USA) in 1994 [14]. Four years later, the World Health Organization (WHO) conducted the first Delphi study, laying the groundwork for a comprehensive list of public health functions. This initiative provided the first global reference for countries to evaluate their public health capacities, emphasizing the significance of proficient management in this domain [15]. Over the past two decades, numerous initiatives have been spearheaded by the World Health Organization (WHO) and its regional branches, alongside other prominent global public health stakeholders such as the Centers for Disease Control and Prevention, the World Bank, the European Commission, as well as various regions and nations. These efforts have been dedicated to the refinement and implementation of essential public health functions [16].

Essential public health functions include a fundamental array of interconnected collective actions essential for reaching public health objectives. These functions are necessary for realizing and sustaining optimal population health levels within available resources, and it is the responsibility of the state to ensure their effective implementation [16],[17]. Lists of essential public health functions are dynamic constructs, prone to periodic revisions and enhancements. They vary in terms of type, quantity, combination, and methods of operationalization, depending on the prevailing interpretation of public health within a specific social context [16].

The original list of essential public health functions in the WHO European Region was based on traditional public health services, emphasizing disease prevention, surveillance, and control, alongside environmental protection, occupational health, and health promotion efforts. The World Health Report 2000 initiated the restructuring of the list, integrating considerations of management, financing, and human resources. Additionally, the terminology shifted, replacing function with operation to differentiate between the fundamental operations of public health and the broader function of the health system [17].

The Health 2020 Strategy [18] and the European Action Plan for Strengthening Public Health Capacities and Services [9] established a cornerstone, elevating population health to a paramount status within all member states of the WHO European Region, consequently reshaping and steering the focus of essential public health operations towards equity, community involvement, and intersectoral governance. During the 62nd session of the WHO Regional Committee in Malta in 2012, a set of 10 key public health operations was adopted [19]. To ensure the delivery of high-quality public health services both within and beyond the healthcare system, complex and multidimensional interactions among essential public health operations are required. Hence, within public health, service provision operations–comprising disease prevention, health promotion, and healthcare–are the main areas of focus. Supervision and monitoring of health status shape these operations and monitor their effectiveness. Meanwhile, management and allocation of human, financial, and material resources, alongside the dissemination of essential knowledge, facilitate the implementation and oversight of essential public health operations [17].

Several WHO global and regional resolutions on strengthening public health capacity and services have been adopted, including WHA69.1 [20]. This resolution advocates for enhancing essential public health functions as the most cost-effective, inclusive, and enduring strategy to realize pivotal health objectives essential for attaining universal health coverage. The resolution highlights the key role of essential public health functions in advancing the sustainable development goals agenda, recognizing their multisectoral character and interconnectedness with health security, governance, and broader health determinants [20].

The COVID-19 pandemic has exposed the weaknesses of health systems worldwide, while concurrently igniting fresh momentum for revitalizing essential public health functions and enhancing emergency response capabilities. In 2021, the WHO introduced a conceptual framework aimed at delineating the scope, definition, and capacity development of the public health workforce. This initiative includes the formulation of a novel list comprising 12 essential public health functions [21] (Table 1). Simultaneously, interconnected drivers crucial for securing sufficient investment and execution of essential public health functions were identified. These include high-level political dedication to public health and its functions, the establishment of multisectoral mechanisms accountable for executing public health functions, and the assessment of their implementation effectiveness [21]. In other words, to strengthen health systems with a robust public health emphasis, clear leadership in public health and effective coordination of intersectoral health activities are imperative; it is essential to enhance multisectoral accountability for executing essential public health functions and to evaluate the current management and implementation status accordingly. The objective is to improve efficiency, effectiveness, and equity in addressing the multifaceted public health challenges of today while striving to attain sustainable development goals [10],[21].

Table 1. Essential Public Health Functions, WHO, 2021

THE SIGNIFICANCE OF PUBLIC HEALTH PROFESSIONALS

Without the involvement of professionals who comprise the public health workforce–responsible for managing, coordinating, and providing essential public health services–the significant progress in public health during the 20th century, characterized by increased life expectancy, improved quality of life, and reduced infant and child mortality, could not have been achieved; their efforts were crucial in reducing and eliminating numerous infectious diseases. Public health professionals play a crucial role in achieving universal health care by investing in essential public health functions and ensuring health safety through the implementation of International Health Regulations [22].

However, health systems worldwide continue to face numerous public health challenges, including aging populations, health inequalities, globalization, migration, urbanization, environmental pollution, and climate change, which contribute to changes in living environments, lifestyles, and disease patterns [4]. Preventable risk factors such as smoking, harmful alcohol consumption, overweight and obesity, unhealthy eating habits, and lack of physical activity contribute significantly to the overall burden of chronic non-communicable diseases, including diabetes, cardiovascular diseases, cancer, and chronic respiratory diseases. These conditions are linked to 90% of deaths and 85% of years lived with disability in the European region [23]. During the COVID-19 pandemic, the frequency of mental health problems in the general population increased significantly. Even before the pandemic, mental health issues were already among the leading causes of disability and posed a serious global public health challenge [23]. Despite public health achievements in combating infectious diseases, such as the eradication of smallpox and the near eradication of polio, there remains a persistent risk of the emergence of new and the resurgence of “old” infectious diseases. This is due to factors such as antibiotic resistance and the increased pace of global travel [4]. Countries in the European region have the highest rate of multidrug-resistant tuberculosis globally. Additionally, the rate of HIV co-infection among people with tuberculosis increased from 7% to 12% between 2010 and 2019 [24]. Recent public health emergencies of international importance, such as influenza, Ebola, Zika, Middle East Respiratory Syndrome, and COVID-19, have highlighted the need for a well-trained, accessible, and efficient multidisciplinary public health workforce [10]. It is realistic to anticipate that controlling chronic non-communicable and infectious diseases will become even more challenging in the future. This is especially true considering the indirect effects of the COVID-19 pandemic, such as delays in healthcare and preventive services [23]. Other public health challenges include the rising number of political conflicts, as well as humanitarian crises such as chemical and radiation incidents, terrorism, and natural disasters like tsunamis, earthquakes, and floods [4],[10].

The Rome Declaration [25], G20 Italy [26], and several resolutions of the World Health Assembly have acknowledged the importance of enhancing the capacity of the workforce responsible for implementing essential public health functions, including preparedness and response during emergencies. They have also emphasized the urgency of implementing these actions.

CHALLENGES RELATED TO PUBLIC HEALTH PROFESSIONALS

The reality is that public health systems worldwide are chronically underfunded, leading to challenges in recruiting an adequate number of qualified public health professionals and ensuring their appropriate distribution. In the United States, for example, there is a well-documented shortage of public health workers both presently and projected for the future. It is estimated that the country will require a minimum of 200,000 new public health professionals during the current decade [27]. Other developed nations, including Canada and numerous European countries, are also facing the challenges of public health workforce shortage. This issue is particularly acute in many developing countries [4],[10]. The COVID-19 pandemic brought to light numerous issues regarding the number, structure, distribution, training, and competency of public health professionals. It became evident that there was a need to increase activities to a level that had probably never been required before [10],[28].

The diverse definitions of public health professionals make it difficult to develop and implement standardized methods for assessing and continuously monitoring the size, composition, and distribution of the public health workforce [28]. In a systematic literature review on defining and determining the number of public health workforce, Watts et al. found that out of 82 publications, only seven offered estimates of the number of public health professionals at the national level. These estimates were provided for 11 countries, including Eritrea, Germany, Italy, Poland, Moldova, Slovenia, England, the Netherlands, New Zealand, Switzerland, and the USA [11].

Public health professionals are not addressed in the European Union’s Directive on the recognition of professional qualifications, nor are they explicitly defined in the International Standard Classification of Occupations by the International Labor Organization. To facilitate evidence-based forecasting of the required number of public health professionals, aligned with the Framework for Action Towards a Sustainable Health Workforce in the WHO European Region, it is crucial to have reliable data sources and standardized methods for monitoring key public health workforce indicators, including mobility and its trends [28].

Some nations still encounter obstacles in introducing public health as an academic discipline or in acknowledging the vital role of public health professionals [29]. The Association of Schools of Public Health in the European Region, in collaboration with the WHO Regional Office for Europe, developed the Competency Framework for the Public Health Workforce [30]. This framework serves as a guide not only for the initial training and job descriptions of public health workers but also for supporting the management, strategic planning, and continuous professional development of the public health workforce. Additionally, they have created the Roadmap to professionalizing the public health workforce [28], which assists countries in enhancing the capacity of their public health workforce to effectively address the increasing public health challenges.

A multitude of causal factors contribute to the complexity of public health workforce challenges, necessitating comprehensive solutions. Challenges concerning the public health workforce can be categorized into several domains: social (an aging workforce, a lack of attractiveness in the profession, low morale and motivation, and retention difficulties), technological (a diverse range of educational offerings and a lack of opportunities for professional development), economic (inadequate funding and low salaries), environmental (antibiotic resistance, pollution, food safety, climate change, and urbanization), political (a low position on political agendas and lack of legal frameworks for workforce development), and legal and ethical (absence of a well-defined ethical framework in public health) [28].

PUBLIC HEALTH PROFESSIONALS IN THE REPUBLIC OF SERBIA

The activities aimed at protecting lives and health, such as organizing quarantines and preventing and eradicating infectious diseases, conducted by the “Department of Quarantine and Sanitation,” established in accordance with the Serbian Constitution of 1839, are regarded as the first organized public health service efforts in the Republic of Serbia. The first half of the 20th century was marked by the establishment of numerous healthcare and public health institutions, including the Institute of Social Medicine and the Central Institute of Hygiene. This period was also characterized by the promotion of public health concepts by prominent individuals. The modern approach to public health began in the 1950s with the analysis and development of projects focused on creating healthy communities. In the latter half of the 20th century, public health gained increased significance, leading to the establishment of a new phase in public health that was based on a holistic approach to health [1]. The beginning of the 21st century was marked by the adoption of Serbia’s Healthcare Bill and the Healthcare System Reform Strategy. These initiatives, grounded in the belief that population health is a public interest and a crucial resource for development, strongly advocated for health promotion, preventive activities, and health partnerships. Over the last two decades, numerous other multisectoral programs have been implemented to support public health priorities [31].

The Ministry of Health, as the primary decision-maker in the healthcare system of the Republic of Serbia, is responsible for the organization, regulation, and supervision in the field of public health. Public health is primarily regulated by the Law on Health Care [32], followed by several other legal statutes, including the Law on Public Health [33] and the Health Insurance Act [34].

The Network Plan regulation [35] defines 26 public health institutes and institutions in the Republic of Serbia, which are the primary agents of public health activities. These institutions are responsible for planning and implementing health promotion, disease prevention, and environmental protection activities, as well as coordinating the work of other participants in the public health system [34]. Health centers, social protection institutions, inspection services, educational institutions, non-governmental organizations, and other entities also play significant roles in the implementation of public health activities.

The education of personnel within the public health system is overseen by the Ministry of Education, Science, and Technological Development. This is accomplished through study programs, specialist and subspecialist training, and continuous public health education. In addition to the four primary specializations in public health–social medicine, epidemiology, hygiene and human ecology, and microbiology and parasitology–since 2022 doctors of medicine have also been able to specialize in public health. These specialist doctors can further specialize in various fields, depending on their primary specialization. These fields include health education, epidemiology of infectious diseases, epidemiology of chronic non-communicable diseases, medical informatics, medical ecology, bacteriology, virology, medical parasitology, and mycology, among others [36]. The current and future threats to public health show the need for an interdisciplinary approach in public health education and multiprofessionalism in the field. To equip public health professionals with the necessary skills to address these threats and take on key roles in health system development and reforms, the School of Public Health was founded in Serbia in 2004. This institution offers postgraduate and continuing education programs in public health, health policy, and healthcare system management [4],[31].

The public health workforce in the Republic of Serbia is predominantly composed of public health professionals and associates employed within public health institutes and institutions. According to the current legal regulations defining personnel requirements for health institutions, a public health institute should have 29 employees per 100,000 inhabitants in its designated territory (22 employees per 100,000 inhabitants in the city of Belgrade). Among these, seven doctors in relevant specialties are required: one each in health promotion, healthcare analysis, planning and organization, informatics with biostatistics, hygiene and human ecology, and two each in disease control and prevention, and microbiology. A national institute of public health should have 32 employees per 1,000,000 inhabitants [37]. There are no precise personnel norms when it comes to public health professionals and associates of other profiles. According to the latest data from public health institutes and institutions, as of 2022, there were 2,662 permanent employees, out of which 393 were medical specialists [38]. The average number of specialist doctors employed in public health institutes and institutions, which was less than 6 per 100,000 inhabitants in the Republic of Serbia, fell below the prescribed personnel standard. Approximately one-fifth of the total workforce in public health institutes and institutions comprises administrative and technical personnel [38]. Among healthcare professionals and associates, alongside doctors, health professionals from various backgrounds predominate, including graduate chemists, physico-chemists, biologists, pharmacy and biochemistry masters, technology engineers, laboratory technicians and nurse-technicians.

The fundamental activities of public health institutes and institutions encompass social-medical, hygienic-ecological, epidemiological, and microbiological aspects. Public health workers are engaged in a wide array of tasks, including: monitoring, assessing, analyzing, and reporting on the population’s health status, health problems, risk factors, and epidemiological situation; promoting healthy lifestyles, preventing risky behaviors, and educating the population about environmental health risks; implementing measures for disease prevention, early detection, and control; conducting sanitary-hygienic and epidemiological surveillance; monitoring and analyzing healthcare use, efficiency, availability, and quality, and providing professional support for improvement; participating in policy development, legal frameworks, plans, and programs for health preservation and improvement, including monitoring and evaluation; contributing to the development and implementation of health information systems; analyzing healthcare system organization, personnel planning, and proposing measures for improvement; managing risks and coordinating public health activities during crises and emergencies, such as epidemics, earthquakes, and floods; collaborating and forming partnerships with other stakeholders in the public health system, including local governments, NGOs, civil societies, and institutions in other sectors; conducting epidemiological, population, and other research in public health, disseminating findings, and informing health authorities for evidence-based decision-making; performing microbiological, parasitological, serological diagnostics, and controlling infectious diseases; conducting physico-chemical, chemical, and toxicological analyses and tests of food, general-use items, water, air, soil, waste, etc. Furthermore, the Institute of Public Health of Serbia “Dr. Milan Jovanović-Batut,” serving as a central institution in the public health system, plays a pivotal role by: coordinating and monitoring the professional activities of all public health institutes and institutions, as well as other entities engaged in public health activities; managing data collection and reporting activities within the healthcare system using expert methodologies; proposing and implementing measures while coordinating efforts with other institutions during crisis and emergency scenarios; and collaborating with international organizations and institutions in the realm of public health on a global scale. Within the Institute of Public Health of Serbia, there is an Organizational Unit for Screening that is responsible for the following: proposing the adoption, modification, and enhancement of screening programs, along with establishing standards and professional-methodological guidelines for their implementation; organizing and monitoring the execution of screening programs, while evaluating their effectiveness; and promoting these programs to raise public awareness about their importance [32].

As a result of public health initiatives and improved healthcare accessibility in the Republic of Serbia, there has been a significant reduction in maternal mortality ratio, which decreased from 17.6 to 11.2 per 100,000 live births between 2010 and 2022. Additionally, infant mortality fell from 10.1 to 4 per 1,000 live births between 2002 and 2022. The mortality rate for children under the age of five also dropped from 11.5 to 5.5 per 1,000 live births between 2002 and 2021 [39]. Over the past two decades, significant progress has been made in the fight against tuberculosis. The tuberculosis notification rate has decreased by more than 80%, reaching 7 per 100,000 population in 2022 [38]. Enhanced availability of reproductive healthcare services and promotional activities in this area have led to a reduction in the birth rate among adolescent girls, an increase in the proportion of women using modern contraceptive methods for family planning, and improved coverage of prenatal care [38],[39]. Promotional activities aimed at raising awareness about the importance of preventive examinations, reproductive health, and vaccination have significantly improved the general health status of vulnerable social groups, such as the Roma population [39],[40]. Over the past two decades, the implementation of an integrated approach to promoting health-responsible behavior has contributed to a reduction in the prevalence of smoking in the population [38].

On the other hand, vital statistics and health indicators in the Republic of Serbia, many of which have deteriorated due to the COVID-19 pandemic, indicate the necessity for further enhancement of public health activities and interventions. This includes strengthening capacities for implementation and the development and strengthening of the public health framework.

In the Republic of Serbia, there is a trend of depopulation and an aging population, driven by negative trends in vital statistics [38],[41]. Although the live birth rate in 2022 shows a slight increase compared to 2021, amounting to 9.4 per 1,000 inhabitants, this indicator has been on a downward trend. In 2020, it reached its lowest value in the past decade, at 8.9 per 1,000 inhabitants [38]. The rate of natural increase has been on a downward trend, showing a lower value in 2022 compared to 2019 (-7 per 1,000 inhabitants in 2022 versus -5.3 per 1,000 inhabitants in 2019). Consequently, the vital index also declined, from 63.5 live births per 100 deaths in 2019 to 57.4 in 2022 [38]. From 2002 to 2022, the proportion of residents under the age of 15 decreased from 16.1% to 14.4%, while the share of those aged 65 and over increased from 16.6% to 22%. Additionally, the average age of the population rose from 40 years to 43.8 years over the same period [41]. Chronic non-communicable diseases such as cardiovascular diseases, malignant tumors, diabetes, and mental health disorders are predominant in the national health profile. Diseases of the circulatory system account for nearly half of all deaths (47.3% in 2022), while tumors are responsible for almost onefifth (18.5%) of all mortality cases [38]. Diabetes is the fifth leading cause of death globally, ranking third in Serbia and fifth in terms of disease burden. Between 2013 and 2022, mortality rates from diabetes increased by 18.9%, while those from heart and blood vessel diseases rose by 4.6% [38]. Unfortunately, there is low coverage of the target population in screening examinations under the national cancer early detection program. Only 11.2% of the target population undergoes colon cancer screenings, 11.6% breast cancer screenings, and 15.8% cervical cancer screenings. This is partly due to inadequate information and awareness among the population regarding the importance of early disease detection and screening examinations [42]. The first national survey of mental health in the Republic of Serbia revealed that 15.2% of the adult population met the criteria for one or more psychiatric disorders [43]. Considering the escalating burden of mental illnesses globally, this emphasizes the need to steer public health interventions towards this area. Moreover, the research showed that excessive alcohol use is the most prevalent issue faced by 7.2% of adult residents [43]. Despite the progress made in reducing smoking prevalence, nearly a third of individuals aged 15 and above in Serbia still smoke tobacco products, significantly exceeding the European Union average of 23%. Furthermore, in 2019, over a third of the adult population (36.3%) were preobese, and more than a fifth were obese (20.8%), which was an increase from 2006 when the obesity rate was 17.3%. Similarly, there has been an increase in obesity among children aged 7 to 14, rising from 2.6% to 10.5% during the same period [44]. Measles vaccine coverage in the Republic of Serbia declined from 93% to 81% between 2013 and 2022 [45]. Additionally, the percentage of the elderly population who received the seasonal flu vaccine in 2019 was at 13.4%, ranking among the lowest compared to other European Union countries [44]. The previously mentioned data indicate a substantial public health challenge in the Republic of Serbia regarding the control of infectious diseases, which is further complicated by the influence of the anti-vaccination movement [31]. The COVID-19 pandemic has highlighted the public health and social responsibilities of professionals in the field, whose prompt and resolute actions were crucial in addressing the crisis. Like in many countries globally, the COVID-19 pandemic exposed the fragility of the public health system in the Republic of Serbia. In 2021, COVID-19 ranked second among the most prevalent causes of death, accounting for 20.3% of deaths. Moreover, during the same year, there was an excess mortality rate of +34.1% compared to the average from 2016 to 2019 [46]. The need to improve personnel capacities in the public health system in order to attain universal healthcare and effectively respond to healthcare emergencies has been emphasized.

The strategic framework for addressing present issues and identifying future directions to ensure an effective response to forthcoming challenges in public health is outlined in Serbia’s Public Health Strategy for 2018-2026 [47]. Based on the promotion of health and the prevention of diseases and injuries and emphasizing the importance of a comprehensive approach through interdisciplinarity, multisectoral cooperation, partnerships, management and communication, the Strategy defines general goals that include the improvement of population, environmental and occupational health, the reduction of inequalities in health, the implementation of community health promotion activities, disease and injury prevention, supporting the enhancement of healthcare availability, quality and efficiency, and development of an evidence-based public health system. Some of the specific strategic goals include developing, empowering, and enhancing the competencies of personnel within the public health system of the Republic of Serbia [47].

The challenges faced by the public health workforce in the Republic of Serbia are comparable to those encountered in developed countries across Europe and worldwide. According to the findings of a study conducted by Šantrić-Milićević et al., which assessed the needs for public health professionals in Serbia, there was a 6% decrease in the number of specialist doctors in public health institutes between 2000 and 2014. Additionally, in the same year, only one-third of these institutes had a number of specialists per 100,000 inhabitants in the district that met or exceeded the prescribed norm by 10%. These statistics highlight an unequal distribution of personnel across districts [48]. According to data from the Institute of Public Health of Serbia “Dr. Milan Jovanović-Batut,” the decline in the number of specialist doctors in public health institutes and institutions has persisted beyond 2014 [38]. Furthermore, there is a recognized shortage of analysts and laboratory technicians in public health laboratories, raising concerns about the public health system’s ability to effectively respond to crisis situations [49]. The turnover intention is becoming more prevalent among public health professionals in institutes and public health organizations, with the prevalence of this phenomenon reaching 27% in 2019. Moreover, there is a growing trend in this inclination, which has been identified and projected to continue [50]. Between 2000 and 2014, the proportion of specialist doctors under the age of 35 within public health institutes and organizations declined from 10% to a mere 2%, while there was also a notable decline in the overall number of specialists, indicating the aging trajectory of the public health workforce in Serbia [48]. In this sense, the public health profession faces an additional challenge in its lesser recognition and acknowledgment compared to clinical medical specialties, both within society and the state. Consequently, it becomes less appealing to young doctors [28].

The challenge of ensuring an adequate number of professionals in the public sector stems from inadequate investment in the Republic of Serbia’s public health system. According to the most recent data from the Institute of Public Health of Serbia, the percentage of expenditures allocated to preventive and public health services decreased from 8.7% to 7.1% of the total health system expenditures between 2003 and 2018 [51]. The funding mechanism for public health institutes and institutions differs from that of other public health institutions. Specifically, services in microbiology, activities regarding mandatory immunization, and other areas within social medicine and epidemiology, defined as programs, are funded through the resources of the Republic Health Insurance Fund. Public health institutes and institutions secure a portion of their funding through annual contracts with the Ministry of Health to execute programs of general interest. These include a range of services such as public health microbiology, disease prevention and control (both infectious and non-infectious diseases), health promotion, health informatics, biostatistics, and health services organization. However, in domains like sanitary microbiology, hygiene, and ecotoxicology, these institutes must compete in the market with other institutions to deliver these specialized services [31].

Personnel planning within the Republic of Serbia’s health system, including public health professionals, often relies on historical data rather than forward-looking projections and the evolving health demands of the population, aiming to sustain the current workforce levels within health institutions [31],[48],[49]. The planning of public health personnel is additionally complicated by the availability and quality of data concerning their quantity, composition, educational backgrounds, skills, and mobility patterns. In the Republic of Serbia, there is currently no strategic framework for planning and developing personnel within the health system, including the public health sector [31].

The WHO work program for Europe spanning 2020 to 2025, “Joint Action for Better Health in Europe,” includes initiatives aimed at assisting in the development of national strategies. These strategies are focused on enhancing working conditions, retaining and motivating the current workforce, and ensuring the future workforce aligns with the health needs of the population, particularly in response to the challenges posed by the COVID-19 pandemic and the requirements for recovery. The program recognizes the significance of gaining a deeper understanding of the healthcare labor market dynamics. This involves actively monitoring the mobility of healthcare professionals to ensure there is a sufficient number of professionals and that they are distributed fairly across the healthcare sector [52].

CONCLUSION

In an era of globalization and ongoing environmental, demographic, economic, and political shifts, addressing global public health challenges demands an infrastructure of well-trained, multidisciplinary public health professionals across diverse local contexts. Building the capacity of a skilled and capable workforce enables delivering high-quality public health services, minimizing health inequalities, and effectively addressing emerging public health challenges [4]. Hence, it’s crucial to grasp the interests and requirements of public health professionals, implement targeted succession planning, improve recruitment and retention strategies, optimize resource utilization, and thereby ensure the creation of a national strategy for public health personnel planning and development. A comprehensive examination of public health personnel management, together with the formulation of strategic and operational personnel policies within the healthcare system of the Republic of Serbia, is imperative to effectively address the challenges posed by crisis situations, such as the outbreak of a novel infectious disease.