Optimizing Georgia’s Public Health Workforce: A Study on Demographics, Engagement, and Capacity Building

Optimizing Georgia’s Public Health Workforce: A Study on Demographics, Engagement, and Capacity Building | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Optimizing Georgia’s Public Health Workforce: A Study on Demographics, Engagement, and Capacity Building Smriti Ridhi, Binita Adhikari, Ekaterine Cherkezishvili, Elene Godziashvili, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7041629/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 May, 2026 Read the published version in Human Resources for Health → Version 1 posted 9 You are reading this latest preprint version Abstract Background: A well-functioning public health system relies on a robust public health workforce. Comprehensive data on the workforce, such as number, distribution, and key characteristics, is crucial for evidence-based workforce planning and development. However, very few comprehensive public health workforce assessments exist, especially in low- and middle-income countries. Public health reforms over the years and needs identified during the COVID-19 pandemic prompted this assessment in Georgia. Methods: A survey of the core public health workforce, including employees at central and regional units of the National Center for Disease Control and municipal public health centers, was conducted online between June and September 2023. The survey collected data on workforce demographics, education, on-the-job training, and time spent across different program areas and job functions. The survey also included questions on career progression within the organization, job satisfaction, and motivation. Results: The response rate to the survey was 81.3%. Findings showed that the median age is 48 for the NCDC workforce and 56 for the MPHCs. Over 80% of NCDC and 90% of MPHC employees are women. Employees have robust pre-service education, with more than half specializing in the public health domain. The mean years of service are 14.9 for NCDC employees and 18.0 for MPHC employees, but career mobility is limited, and salary structures vary by region. Despite long tenures, only 33.3% of NCDC and 10.5% of MPHC staff have ever been promoted. At NCDC, the largest share of employee time is spent on administrative program areas, and surveillance and response, while MPHC employees primarily focus on communicable disease management, administration, and immunization. Participation in training is limited, with employees in key positions having better access to training. The workforce reports reasonable satisfaction and finds substantial intrinsic motivation in their work. Conclusions: The insights gained from this study are pivotal in identifying workforce planning and development bottlenecks in Georgia and developing targeted strategies. Key areas for intervention include recruiting workers to meet emerging public health needs, providing competitive salaries to attract a younger workforce, and strengthening training offerings. This effort to profile the public health workforce could guide similar assessments in the future and in other countries to prevent, detect, and respond to public health threats. Public Health Workforce Workforce Development Workforce Survey Figures Figure 1 Figure 2 Figure 3 Background The public health workforce is the foundation of the public health infrastructure within a country ( 1 ). Having the right people with appropriate skills and competencies is critical to addressing complex public health challenges ( 2 ). In order to understand a country's ability to effectively deliver public health services, quantifying and understanding key characteristics of its public health workforce is imperative ( 3 ). While substantial work has been done to date to map the health care workforce ( 4 , 5 ), there is very little analysis, especially in low- and middle-income countries, of the public health workforce. Insights into workforce size, distribution and composition, education and training, engagement, and other human resource practices promote evidence-based workforce planning decisions ( 6 )and support a systematic approach to workforce development ( 7 ). Building this understanding and guiding strategic investments in workforce development hinges on the availability of comprehensive data ( 8 ). However, enumerating and characterizing the health workforce can be challenging due to limited or unreliable Human Resource Information Systems (HRIS) ( 9 ). The situation is even more complicated for the public health workforce, where clear definitions of who constitutes the workforce are often lacking. The WHO and Association of Schools of Public Health in the European Region (ASPHER) " Roadmap to Professionalizing the Public Health Workforce in the European Region" defines the core public health workforce as all the individuals who provide essential public health operations as their primary role ( 10 ). Gebbie et al. characterize core public health professionals as individuals employed by government public health agencies who work closely with other public and private organizations ( 11 ). Other attempts at workforce enumeration have defined the public health workforce by the institution they are employed at or their occupational classification ( 12 , 13 ). Utilizing these approaches, there have been a handful of attempts at mapping the public health workforce at a national level through surveys, reviews of routine data, and other data collection techniques. In the United Kingdom, the Centre for Workforce Intelligence conducted a mapping of the public health workforce in England to guide policy decisions for workforce planning ( 14 ). The methodology reviewed the literature and estimated the numbers of workers based on administrative records, primarily assessing workforce distribution and skills ( 14 ). In the United States, a nationally representative survey of public health employees, the Public Health Workforce Interests and Needs Survey (PH WINS), has been conducted three times. The survey has captured workforce demographics, characteristics, training needs, retention metrics, and engagement & satisfaction ( 15 , 16 ). Other studies have sought to enumerate the workforce ( 17 ), identify their training needs ( 18 , 19 ), and identify challenges faced by the workforce ( 3 ). A study by Bjegovic-Mikanovic et al. synthesized qualitative data from workforce development success stories reported by the South-Eastern Europe Health Network (SEEHN) to share a high-level view of who the public health workforce is, and the type of essential public health functions performed by the workforce ( 20 ). In 2004, a study in the country of Georgia collected data on public health workers’ demographics, employment history, education, and on-the-job training, as well as opinions on HR management practices and policies and funding levels in the municipalities. The methodology included conducting a survey of directors and one employee from 30 randomly selected municipal public health centers and Focus Group Discussions among local public health professionals, center directors, and policymakers ( 21 ). Government leadership in Georgia identified workforce assessment as a priority based on needs identified during the COVID-19 response. The public health system in Georgia has undergone considerable restructuring and reforms over the years, particularly since the dissolution of the Soviet Union in 1991 ( 22 ). The country established new public health infrastructures and shifted focus from the sanitary-epidemiological service model to a more holistic approach to public health ( 23 ). The apex agency for public health in the country, the National Center of Disease Control and Public Health (NCDC), was established in 1996. The NCDC oversees all essential public health functions within the country and sets standards and regulations for public health and biosecurity ( 24 ). It also manages and coordinates regional public health divisions. NCDC is supported by 65 municipal public health centers (MPHCs) spread across 11 administrative regions ( 25 , 26 ). The MPHCs deliver public health services at the local level through various frontline public health workers. The employees across NCDC, its regional units, and the MPHCs constitute the core public health workforce in the country. Changes in the public health infrastructure, evolving public health needs, and the impact of the COVID-19 pandemic accentuate the need for workforce assessment. Our study aimed to map the existing core public health workforce in Georgia, assessing workforce composition, demographics, workforce distribution by job function and geography, and levels of satisfaction and workforce engagement. This study was conducted to inform the development of a public health workforce strategy for the country and advance Georgia’s capability to perform essential public health functions and prevent, detect, and respond to disease threats. Methods Aim and Setting of the Study We conducted a public health workforce survey in Georgia between June and September 2023. The study population included public health professionals in Georgia employed at the central and regional units of the NCDC and in 65 MPHCs distributed across 11 regions in the country. The survey excluded personnel in the Department of Technical Support and the Legal Department in NCDC, as well as drivers, janitors, and administrative assistants across NCDC and MPHCs who were determined to be support staff rather than core public health workers. The survey respondents included both permanent employees and employees on contract. The survey was administered to 390 of 446 employees in NCDC central and regional offices; the remaining staff classified as support personnel and therefore excluded. For the MPHCs, the survey was administered to 734 of 974 employees, excluding support staff. An organogram of the NCDC outlining the departments and divisions is included as additional material-1. Questionnaire Development and Survey Process The survey was developed by the Johns Hopkins University team and refined based on feedback from workforce experts in NCDC Georgia and the US Centers for Disease Control and Prevention’s (CDC) country office in Georgia. The instrument drew upon existing public health workforce surveys, including the PHWINS ( 27 ), the Council on Linkages Public Health Workers Survey Instrument ( 28 ), and other validated workforce engagement questions ( 29 ). The job program area classification was informed by the PHWINS classification conducted in the United States to characterize employees working in State Health Agencies and was refined for contextual relevance ( 15 , 16 ). Most of the questions in the survey were closed questions, but a few questions offered opportunities for explanation. The survey (additional material 2) collected data on workforce demographics, including name, age, sex, work location, work unit, position, nature of employment, and hours worked. It also included fields on education level and focus area, as well as participation in on-the-job training. Employees were asked to indicate the percentage of time spent across different program areas and job functions, and if they held any additional positions. A section of the survey included questions on career progression within the organization. Respondents were asked to rate their job satisfaction level on a scale of 1 to 5, (where ( 1 ) is extremely dissatisfied and ( 5 ) is extremely satisfied) with different aspects of work, including pay and benefits, job duties, work culture (working hours, supervisory support, acknowledgment), and job security. Workforce engagement was also assessed by asking questions about the three most important reasons for joining and staying at the organization. The final section of the survey included questions on performance review, employees’ sense of being supported, and plans to retire. Survey Administration The survey was conducted by the NCDC leadership in English and Georgian and administered online using Qualtrics. For NCDC staff, an individualized survey link was generated through Qualtrics and emailed to all participants. In the case of MPHCs, a survey link was sent to the municipal center head, and s/he circulated it to the intended recipients as there was no central database with emails for all relevant staff. The survey was open from June 8, 2023, to September 29, 2023, and 4 rounds of follow-up were conducted. For NCDC employees, two auto reminders were sent through Qualtrics, and the head of Continuing Professional Development sent follow-up email reminders after that. For MPHC employees, the head of the unit followed up through email to increase the response rate. Data Analysis Survey responses with less than 40% completion were considered incomplete and removed from the data set, as were any duplicate responses. Open fields were translated from Georgian to English using Google Translate, and a sample of these translations was reviewed by a team member fluent in both Georgian and English to ensure accuracy. Such open fields were also cleaned through a manual review, correcting misspellings and typos. In some cases, open fields were converted into categories of responses to allow easier analysis. The dataset was checked for outliers and erroneous entries in numerical fields (e.g., age, monthly salary, number of hours worked), and these errors were excluded from data analysis. The public health workforce distribution analysis was conducted using the 2023 Georgia population estimates published by the National Statistics Office of Georgia ( 30 ). Statistical analysis was conducted using R Studio Version − 2023.09.1 + 494 and Microsoft Excel. Findings were presented to and discussed with local stakeholders to verify key results and enhance interpretation. Results The overall response rate of the survey was 81.3%; 914 responses were received out of 1124 public health employees approached. A total of 272 responses were received from the NCDC and regional NCDC centers, resulting in a response rate of 69.7%. The response rate for municipal centers was 87.5%. Response rates by NCDC departments and MPHC regions are included as additional material 3 and additional material 4. Distribution of public health workers In NCDC, 18.2% of the workforce is assigned to divisions within the Lugar Center for Public Health Research, the reference laboratory for public health in Georgia. Around 10.0% of employees work in the Communicable Diseases Department, 5.6% in Non-Communicable Diseases, 4.9% in the Department of Medical Statistics, and 1.5% in the Environmental Health Department. The total core public health workforce in the finance, administration, public relations, and quality control divisions accounts for 7.5%. A very small percentage (1.3%) are employed in the Risk Preparedness Division and the Division of Continuing Professional Training and Development. The Department of Public Health State Programs Central and Regional Management within NCDC provides direct support to the MPHCs through nine regional offices, where 22.3% of employees work. A significant proportion (28.7%) of NCDC employees are engaged in state programs, which are vertical programs funded by the state budget and administered by the NCDC. These programs are focused on domains such as HIV/AIDS, COVID-19, hepatitis, tuberculosis, blood safety, and disease prevention. At NCDC, 78.7% of staff are in permanent positions. At the local level, the density of the public health workforce in municipal units varies from 9 to 114 workers per 100,000 population (Table 1 ). A higher density of public health workers is seen in mountainous regions such as Svaneti. The workforce across most municipal centers except two (Adjara and Tbilisi) have similar key positions. However, the number of employees working in these positions varies and is not correlated with the population served. Across the nation there are 30.1 core public health workers per 100,000 population. Table 1 Distribution of public health employees MPHC Region Population of Region Core Public Health Workforce Public health workers per 100000 people Adjara* 361,411 33 9.1 Guria* 104,338 34 32.6 Imereti* 463,068 153 33.0 Kakheti* 306,216 85 27.8 Kvemo Kartli 442,771 91 20.6 Mtskheta-tianeti* 93,253 47 50.4 Racha/Kvemo Svaneti* 27,120 31 114.3 Samegrelo/Zemo Svaneti* 299,290 115 38.4 Samtskhe-Javakheti* 147,352 56 38.0 Shida Kartli* 249,829 47 18.8 Tbilisi** 1,241,709 42 3.4 NCDC n/a 390 n/a National 3,736,357 1124 30.1 *Regions with regional NCDC offices **Tbilisi also houses the main NCDC offices and benefits from these national level employees Key positions at MPHCs include epidemiologists who are responsible for disease surveillance and preventive care services (20.8% of MPHC public health workforce); employees in immunization programs (11.7%); medical-statistical informaticians (7.6%); preventionist/prophylactic doctors (7.6%); parasitologists (5.6%); entomologists (5.0%); lab and other assistants (10.2%); there are several other positions at the MPHCs that make up a smaller proportion of the workforce. Most (84.4%) of the MPHC employees are in permanent positions. Workforce Characteristics Half of the workforce is above the age of 48 in NCDC and 56 in MPHCs. The mean years of service for NCDC employees is 14.9 years, and for MPHC employees is 18.0 years. Despite long tenures within each organization, only 33.3% of NCDC and 10.5% of MPHC staff have ever received a promotion. On average, fewer than 20 employees join NCDC and the MPHCs annually. Hiring is usually driven by organizational restructuring or increased public health needs, such as during the COVID-19 pandemic. There were surges in recruitment associated with the NCDC establishment (1996), the public health system reorganization (2007), the establishment of the Lugar Center (2012), and the COVID-19 pandemic (Fig. 1 ). The workforce is predominantly female, with 81.6% of the employees at NCDC and 90.3% at MPHCs being women. At the time of the survey, the median salaries for key positions at NCDC ranged from 750 Georgian Lari (GEL) (approximately 277 USD) per month to 2420 GEL (893 USD) per month. For MPHCs, median salaries were between 484 GEL (179 USD) per month and 1611 GEL (594 USD) per month. Among MPHC employees, we observed significant regional differences in salary for people working in the same position. The salary in some regions was half that of others. Educational background and qualifications of public health professionals Public health employees in Georgia have robust pre-service education (Table 2 ). Most NCDC employees have a master's degree or higher, and more than half of the employees with master's and bachelor's degrees specialized in public health or medicine. In MPHCs, one-quarter of staff have master's degrees, and a similar proportion have medical degrees attained through a single cycle program (programs that lasted for five years or more and issued 'specialist' diplomas upon graduation) before 1994 ( 31 ). MPHC employees' domain of education showed a similar trend to that of NCDC. Table 2 Distribution of Public Health Workforce by Educational Qualification Educational Qualification NCDC staff Municipal staff Doctoral Degree 10.7% (n = 29) 0.5% (n = 3) Masters' Degree 44.5% (n = 121) 25.2% (n = 162) One (single)-cycle program (Medical Doctors, Dentists) or any other not specified University degree (e.g., graduates before 1994) 15.8% (n = 43) 24.3% (n = 156) Bachelor's Degree 16.9% (n = 46) 23.9% (n = 153) Specialized Secondary ("Technicum")/college (5th level certificate for recent graduates, e.g., Nursing Training) 11.8% (n = 32) 20.9% n = 134) High School or Professional (vocational) school 0.4% (n = 1) 5.3% (n = 34) Continuing Professional Development Among survey respondents, 79.7% of NCDC employees and 80.2% of MPHC employees reported participating in some form of on-the-job training since assuming their positions. Most training opportunities focused on COVID-19, contract tracing, epidemic surveillance and response, and immunization. The frequency of participation in training differed between departments. Within departments at the NCDC, recent training participation was evenly distributed among key positions. Participation in training by cadres reflected a higher median age among trainees. Time spent across program areas In NCDC, the largest share of surveyed employees’ time is spent on administrative program areas (21.9%) and public health surveillance and response (21.1%). This is followed by communicable disease management (19%), data collection, management, monitoring and evaluation (8.1%), emergency management, including the workforce engaged in COVID-19 response (6.1%), and immunization (5.3%). In comparison, NCDs (4.1%) and health promotion (2.8%) have less dedicated employee time. Less than 2% of the effort is spent on workforce development, clinical services, and policy and legislation development. The program areas where MPHC employees spend most of their time are communicable disease management (25.3%), administration (16.3%), immunization (14.9%), and emergency response, including COVID-19 (8.6%). Non-communicable diseases (2.3%), injury prevention (2.4%), workforce development (0.2%), and policy and legislation (0.1%) have a lower proportion of dedicated workforce time. The distribution of employee effort by program area is depicted in Fig. 2 . Within these program areas, 40.8% of employee effort at NCDC goes to program implementation, and the second highest allocation of time goes to research (21.8%). A similar distribution was seen at MPHCs, where 43.0% of time goes towards program implementation, and 16.6% is dedicated to research. Perceptions of job satisfaction, engagement, and motivation As Fig. 3 shows, most respondents had relatively high job satisfaction. It is notable that the two items receiving the lowest scores both for NCDC and MPHC staff were (i) pay and benefits and (ii) career progression. On average, satisfaction appeared to be greater among MPHC staff than NCDC staff. We found no correlation between age and satisfaction for either NCDC or MPHC employees. Satisfaction with work culture was higher among employees who received some kind of performance review. Employees who had been promoted at some point expressed higher satisfaction with career progression. Respondents were also asked to state their level of agreement with a series of statements concerning job motivation. The results presented in Table 3 are positive overall, but for both NCDC and Municipal staff, the lowest scoring items were related to training received on the job and the extent to which this met their needs. Table 3 Mean Motivation Scores for NCDC and MPHC employees Mean Score Item NCDC staff Municipal staff My job is meaningful, and I feel a sense of pride in doing my job 4.50 4.58 Overall, the training I received on the job meets my needs 3.98 4.12 I feel appreciated and supported by the organization that I work for 3.98 4.48 I feel appreciated and supported by my supervisor 4.33 4.57 Respondents were also asked to identify from a list of options the three top reasons for staying in their jobs. For NCDC staff, the most frequently cited reasons were challenging work, a sense of mission, and satisfaction with their supervisor. For MPHC staff, the most common reasons were job satisfaction, satisfaction with their supervisor, and a sense of mission. Very few respondents cited a lack of opportunity elsewhere. Reasons to stay in the job didn't show any specific patterns when reviewed by age groups. The most important reason for joining the organization for both NCDC and MPHC employees was their interest in job functions, followed by the reputation of the organization. Around half of NCDC employees and 70.6% of MPHC employees reported receiving some form of performance feedback, and overall, they found these useful. However, there is no formal performance review process at NCDC or in the municipal offices, except at the Lugar Center at NCDC. Discussion Survey findings suggest many positive factors: the current workforce in Georgia is stable as most of the employees are in permanent positions; the workforce is well-trained in terms of pre-service education; and the longer tenure of employees suggests a wealth of knowledge gained on the job. Furthermore, the public health workforce appears satisfied and finds substantial intrinsic motivation in their work. There have been very few other public health workforce surveys in middle-income countries, so it is difficult to compare results, however, some of the findings from this survey align with what has been found in high-income countries. For example, Sellers et al. found that the state public health workforce in the US is also heavily female (72%) and has a median age of 50 ( 15 ). Similarly, Robin et al. found that 81% of local public health workers were female and also trended older ( 32 ). This compares to a median age of 48 years and 80% female at NCDC and 56 years and 90% female at MPHCs in Georgia. In contrast to the US, where most public health workers had been in their positions for 5 years or less ( 32 ), public health workers in Georgia have had long tenures within their organization and limited career mobility. The core public health workforce density of 30.1 employees per 100,000 population in Georgia is lower than other countries in the region, such as Poland (44.7), Moldova (57.1), and Slovenia (58.0), and falls significantly short of high-income countries such as Switzerland (102.6) and the United States (104.2) ( 12 ), ( 33 ). It is important to note that the definition of public health workforce across countries in these studies is not consistent, making comparisons difficult. However, the assessment of the public health workforce in Poland included employees working across government public health agencies and local health units, similar to our study ( 33 ). We found substantial variation in the density of municipal public health workers across regions within the country, which was difficult to explain. An earlier study in Georgia also noted the unequal distribution of public health workers but observed a concentration of such workers in urban rather than rural areas ( 21 ). Some explanatory factors that we considered, such as the presence of an NCDC regional office, which might substitute for MPHC staff, or MPHCs with a higher density of staffing having an older workforce (who were disinclined to retire), were not supported by the data. The particularly low workforce density in Adjara is likely explained by a different staffing model in this autonomous region, where there is far greater centralization of public health staff, which may present a more efficient model for the country to consider in the future. Otherwise, we believe regional variations may be due to idiosyncratic staffing practices within MPHCs that could be addressed through clearer central guidelines on MPHC staffing. Indeed, since these survey findings were presented, the Ministry and NCDC have moved towards issuing such guidance. Bogaert et al. reported that only 19% of state health employees in the US had a degree in a public health domain at any educational level based on the PHWINS ( 18 ). A significantly higher percentage (29%) of Georgian public health employees have received a degree in specific public health domains or preventative medicine, and another 11% are medical doctors. Also, 53% of the workforce in Georgia have a master's degree compared to 31% reported by Bogaert et al in the US ( 18 ). However, this comparison is slightly nuanced due to the structure of the education system in Georgia until 1994, when single-cycle programs were offered and considered equivalent to a master's degree. Thereafter, these degrees were split into a two-tier system - a four-year bachelor's and a two-year master's ( 31 ). Nonetheless, this observation of a more highly educated workforce than other countries aligns with other studies on the general health workforce that note that Georgia has a high availability of qualified physicians, even compared to other countries in the region ( 26 ). Public health workforce salaries in Georgia are relatively low compared to other similar roles within the country. The National Statistics Office in Georgia reported that the average monthly salary for public administration and social security workers is around GEL 1,823 ( 34 ), approximately twice that of many key public health positions. Our discussions with universities offering public health courses suggested that lower salaries compared to private sector employees act as a barrier to graduates opting for government public health positions. Both satisfaction and motivation among Georgian public health workers appeared high despite limited prospects for promotion and relatively low pay. Other studies of health worker motivation in Georgia have also found this ( 35 ) and noted that factors such as good relationships with supervisors, and a sense of meaning in work are key. However, it should be noted that US studies have shown high job satisfaction but also a high intent to leave ( 15 , 32 ). Since the survey was employer-led, we avoided questions about employees' intention to leave, but it is clear that turnover among public health workers in Georgia is very low. We faced challenges in collecting accurate data on training conducted during the past two years, but workers' responses suggest that improved training opportunities may enhance workforce motivation. This resonates with an earlier study that also concluded that improved opportunities for continuing education in the public health workforce were key to workforce development ( 21 ). A higher median age among trainees who received training opportunities indicates that younger members of the workforce who might be able to apply skills for a longer period may need additional targeted training interventions to address their needs and support long-term career development goals. This survey indicates several areas in which NCDC may intervene to strengthen the public health workforce: most notable is a need to recruit public health workers to address areas of emerging importance such as environmental health and health promotion (especially for non-communicable diseases), providing competitive salaries to attract a younger workforce, and strengthening the array of training opportunities offered. This profile of Georgia’s public health workforce allows the government to understand better its capabilities to prevent, detect, and respond to public health threats and prepare for future epidemics and pandemics. Understanding the training needs of the public health workforce would also allow the government and partners to tailor and provide appropriate training opportunities targeting specific capacity development needs, building accountability and career pathways, and being more effective and efficient with their resources. The government is in the process of approving a new public health workforce strategy that adopts many of these recommendations. Salaries for the public health workforce increased by approximately 10% for each cadre in early 2024 after this survey was conducted, and several other changes are also underway. Limitations of the study This survey was sponsored and administered by NCDC, and while respondents were assured that their responses would remain anonymous, there may nonetheless be a social desirability bias in responses, with participants sometimes providing information that their employer would expect and not revealing more negative attitudes. We also recognize that by focusing on the core public health workforce, our survey failed to cover many health workers who contribute to public health as part of their jobs (albeit not their primary focus). Accordingly, the survey provides an incomplete picture of how public health functions are carried out in Georgia. Despite this, we believe this study provides important information about issues facing the core public health workforce in the country. Conclusions This is the first national survey of Georgia's core public health workforce. Survey findings present a comprehensive overview of workforce distribution by job function, geography, key characteristics, and their level of satisfaction, motivation, and engagement. The insights gained are critical in identifying and addressing workforce planning and development bottlenecks. First, understanding how the current workforce spends their time aids in aligning workforce planning to public health needs and the country's disease profile. Second, the findings indicate the importance of accelerating investment in training, especially for younger members of the workforce. Third, we found relatively low salary levels and unexplained variation in salaries, suggesting that efforts to increase and standardize salaries may be warranted to promote even-handedness and improve motivation. Finally, this initial effort to profile the public health workforce could guide similar assessments in the future in Georgia, providing an opportunity to track how human resource policies are affecting the workforce. Georgia's experience could also serve as a reference to other post-Soviet countries in the region as they advance their public health workforce to address country and regional priorities. These efforts contribute to improving health security and pandemic preparedness. Similar assessments of the public health workforce elsewhere could help provide an evidence-based approach to workforce planning and development. Abbreviations If abbreviations are used in the text, they should be defined in the text at first use, and a list of abbreviations should be provided. Abbreviation Meaning EPHFs Essential Public Health Functions FETP Field Epidemiology Training Program FTEs Full-Time Equivalents HRIS Human Resource Information System JHU Johns Hopkins University MoH Ministry of Internally Displaced Persons from the Occupied Territories, Health, Labour and Social Affairs MPHCs Municipal Public Health Centers NCDC National Center for Disease Control and Public Health SEEHN South-Eastern Europe Health Network US CDC United States Centers for Disease Control and Prevention Declarations All manuscripts must contain the following sections under the heading 'Declarations': Ethics approval and consent to participate. Ethical clearance was received from the Institutional Review Board (IRB) of the National Center for Disease Control and Public Health of Georgia (Ref: IRB # 2023-037, Dated - June 2, 2023). Written informed consent was incorporated at the beginning of the online survey, requiring participant acknowledgment before proceeding with the survey. Consent language and process were approved by the IRB. Data management was conducted as per IRB approvals. All scientific data collected was preserved in a password-protected Microsoft One drive database provided by JHSPH IT. The database was only available to study team members. The survey was administered and collected through Johns Hopkins Qualtrics and was available to the study team through JHU institutional login details. Identifiers such as names, email addresses, and phone numbers were deleted from the survey data before data analysis. Consent for publication - Not applicable. Availability of data and materials - The datasets generated and/or analyzed during the current study are not publicly available to protect participant privacy. Competing interests - The authors declare no competing interests. Funding – Funding for this research was provided under a grant by the US CDC to the Johns Hopkins School of Public Health team. Authors' contributions Survey Tool Development – S.R., E.C developed the first draft of the survey tool. S.B. and B.A reviewed and revised the tool. E.G and T.S. reviewed and shared inputs for tool contextualization and improvement. Survey Administration – E.G., led the survey administration with the support of E.C and S.R. Manuscript writing – S.R. wrote the first draft of the manuscript, S.B., and B.A. reviewed and shared significant inputs to improve the manuscript. All authors read and approved the final manuscript. Acknowledgements –This work was conducted with support from the US CDC NPHI program under Award No. NU2HGH000014. Authors' information (optional) Required Disclaimer: The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of [the U.S. Centers for Disease Control and Prevention. References Woltring CS, Novick LF. Public health workforce: infrastructure's keystone. J Public Health Manag Pract. 2003;9(6):438-9. Otok R, Richardson E, Czabanowska K, Middleton J. The public health workforce In: Rechel B, Jakubowski E, McKee M, Nolte E, editors. Organization and financing of public health services in Europe2018. Lichtveld MY, Cioffi JP. Public Health Workforce Development: Progress, Challenges, and Opportunities. Journal of Public Health Management and Practice. 2003;9(6):443-50. Boniol M, Kunjumen T, Nair TS, Siyam A, Campbell J, Diallo K. The global health workforce stock and distribution in 2020 and 2030: a threat to equity and 'universal' health coverage? BMJ Glob Health. 2022;7(6). Liu JX, Goryakin Y, Maeda A, Bruckner T, Scheffler R. Global Health Workforce Labor Market Projections for 2030. Hum Resour Health. 2017;15(1):11. Martineau T, Ozano K, Raven J, Mansour W, Bay F, Nkhoma D, et al. Improving health workforce governance: the role of multi-stakeholder coordination mechanisms and human resources for health units in ministries of health. Hum Resour Health. 2022;20(1):47. Dubois CA, Singh D. From staff-mix to skill-mix and beyond: towards a systemic approach to health workforce management. Hum Resour Health. 2009;7:87. Collaborators GBDHRfH. Measuring the availability of human resources for health and its relationship to universal health coverage for 204 countries and territories from 1990 to 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2022;399(10341):2129-54. McQuide PA, Brown AN, Diallo K, Siyam A. The transition of human resources for health information systems from the MDGs into the SDGs and the post-pandemic era: reviewing the evidence from 2000 to 2022. Hum Resour Health. 2023;21(1):93. Europe WROf. ROADMAP TO PROFESSIONALIZING THE PUBLIC HEALTH WORKFORCE IN THE EUROPEAN REGION. 2022. Gebbie K, Merrill J, Tilson HH. The public health workforce. Health Aff (Millwood). 2002;21(6):57-67. Watts RD, Bowles DC, Ryan E, Fisher C, Li IW. No Two Workforces Are the Same: A Systematic Review of Enumerations and Definitions of Public Health Workforces. Front Public Health. 2020;8:588092. Beck AJ, Meit M, Heffernan M, Boulton ML. Application of a Taxonomy to Characterize the Public Health Workforce. J Public Health Manag Pract. 2015;21 Suppl 6:S36-45. Intelligence CfW. Mapping_the_core_public_health_workforce. 2014. Sellers K, Leider JP, Harper E, Castrucci BC, Bharthapudi K, Liss-Levinson R, et al. The Public Health Workforce Interests and Needs Survey: The First National Survey of State Health Agency Employees. J Public Health Manag Pract. 2015;21 Suppl 6(Suppl 6):S13-27. Halverson PK. Ensuring a Strong Public Health Workforce for the 21st Century: Reflections on PH WINS 2017. J Public Health Manag Pract. 2019;25 Suppl 2, Public Health Workforce Interests and Needs Survey 2017(2 Suppl):S1-S3. Merrill J, Btoush R, Gupta M, Gebbie K. A history of public health workforce enumeration. J Public Health Manag Pract. 2003;9(6):459-70. Bogaert K, Castrucci BC, Gould E, Rider N, Whang C, Corcoran E. Top Training Needs of the Governmental Public Health Workforce. J Public Health Manag Pract. 2019;25 Suppl 2, Public Health Workforce Interests and Needs Survey 2017(2 Suppl):S134-S44. Jacob RR, Baker EA, Allen P, Dodson EA, Duggan K, Fields R ea. Training needs and supports for evidence-based decision making among the public health workforce in the United States. BMC Health Services Research. 2014. Bjegovic-Mikanovic V, Santric-Milicevic M, Cichowska A, von Krauss MK, Perfilieva G, Rebac B, et al. Sustaining success: aligning the public health workforce in South-Eastern Europe with strategic public health priorities. Int J Public Health. 2018;63(5):651-62. Djibuti M, Gotsadze G, Mataradze G, Menabde G. Human resources for health challenges of public health system reform in Georgia. Hum Resour Health. 2008;6:8. Marina K, Charlotte K, Erica R. Trends in health systems in the former Soviet countries. In: Rechel B, Richardson E, McKee M, editors. European Observatory Health Policy Series. European Observatory Health Policy Series. Copenhagen (Denmark)2014. Gotsadze G, Chikovani I, Goguadze K, Balabanova D, McKee M. Reforming sanitary-epidemiological service in Central and Eastern Europe and the former Soviet Union: an exploratory study. BMC Public Health. 2010;10:440. Health LSNCfDCaP. Strategic Plan 2018-2022 [Available from: https://www.ncdc.ge/#/pages/file/22705b5c-31b7-40f4-a0f7-163796f933c6. Verulava T, Jorbenadze A. "Development of Public Health in Georgia: Challenges and Policy Issues". Archives of the Balkan Medical Union. 2022;57(2):179-84. Gamkrelidze A, Atun, Rifat, Gotsadze, George. et al. . Health Care Systems in Transition. 2002. Leider JP, Bharthapudi K, Pineau V, Liu L, Harper E. The Methods Behind PH WINS. J Public Health Manag Pract. 2015;21 Suppl 6(Suppl 6):S28-35. Foundation PH. Council on Linkages Public Health Workers Survey Instrument [Available from: https://www.phf.org/resourcestools/Documents/Public_Health_Worker_Survey.pdf. Wiley JW. Using Employee Opinions about Organizational Performance to Enhance Employee Engagement Surveys: Model Building And Validation. HR People & Strategy. 2014. GEORGIA NSOO. NUMBER OF POPULATION 2023 [Available from: https://www.geostat.ge/media/53004/Number-of-Population-as-of-January-1%2C-2023.pdf. L M, N G. The many faces of research assessment: Case of independent Georgia. Journal of Research and Innovation in Higher Education. 2023. Robin N, Castrucci BC, McGinty MD, Edmiston A, Bogaert K. The First Nationally Representative Benchmark of the Local Governmental Public Health Workforce: Findings From the 2017 Public Health Workforce Interests and Needs Survey. J Public Health Manag Pract. 2019;25 Suppl 2, Public Health Workforce Interests and Needs Survey 2017(2 Suppl):S26-S37. Organisation WH. Organization and financing of public health services in Europe Country Reports2018. GEORGIA NSOO. Employment and Wages 2023 [Available from: https://www.geostat.ge/en/modules/categories/39/wages. Franco LM, Bennett S, Kanfer R, Stubblebine P. Determinants and consequences of health worker motivation in hospitals in Jordan and Georgia. Soc Sci Med. 2004;58(2):343-55. Additional Declarations No competing interests reported. Supplementary Files AdditionalFile1.docx Additional Files : File name : Additional File 1 · File format including the three-letter file extension – Word, .doc · Title of data - NCDC Organogram · Description of data - An organogram of the National Center for Disease Control and Public Health, Georgia outlining the departments and divisions. AdditionalFile2.pdf File name : Additional File 2 File name : Survey instrument · File format including the three-letter file extension – pdf, .pdf · Title of data – Survey Instrument · Description of data – Survey tool used for this research study AdditionalFile3.docx File name : Additional File 3 · File format including the three-letter file extension – Word, .doc · Title of data - Response rate from NCDC and Regional NCDC offices · Description of data – Table showing the survey response rate for participants in NCDC central and regional offices AdditionalFile4.docx File name : Additional File 4 · File format including the three-letter file extension – Word, .doc · Title of data - Response rate from Municipal Public Health Centers · Description of data – Table showing the survey response rate for participants in Municipal Public Health Centers Cite Share Download PDF Status: Published Journal Publication published 02 May, 2026 Read the published version in Human Resources for Health → Version 1 posted Editorial decision: Revision requested 15 Mar, 2026 Reviews received at journal 12 Mar, 2026 Reviewers agreed at journal 25 Feb, 2026 Reviews received at journal 01 Sep, 2025 Reviewers agreed at journal 25 Aug, 2025 Reviewers invited by journal 12 Aug, 2025 Editor assigned by journal 04 Jul, 2025 Submission checks completed at journal 04 Jul, 2025 First submitted to journal 03 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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competing interests reported.","formattedTitle":"Optimizing Georgia’s Public Health Workforce: A Study on Demographics, Engagement, and Capacity Building","fulltext":[{"header":"Background","content":"\u003cp\u003eThe public health workforce is the foundation of the public health infrastructure within a country (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Having the right people with appropriate skills and competencies is critical to addressing complex public health challenges (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In order to understand a country's ability to effectively deliver public health services, quantifying and understanding key characteristics of its public health workforce is imperative (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). While substantial work has been done to date to map the health care workforce (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), there is very little analysis, especially in low- and middle-income countries, of the public health workforce. Insights into workforce size, distribution and composition, education and training, engagement, and other human resource practices promote evidence-based workforce planning decisions (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)and support a systematic approach to workforce development (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBuilding this understanding and guiding strategic investments in workforce development hinges on the availability of comprehensive data (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, enumerating and characterizing the health workforce can be challenging due to limited or unreliable Human Resource Information Systems (HRIS) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The situation is even more complicated for the public health workforce, where clear definitions of who constitutes the workforce are often lacking. The WHO and Association of Schools of Public Health in the European Region (ASPHER) \u003cb\u003e\"\u003c/b\u003eRoadmap to Professionalizing the Public Health Workforce in the European Region\" defines the core public health workforce as all the individuals who provide essential public health operations as their primary role (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Gebbie et al. characterize core public health professionals as individuals employed by government public health agencies who work closely with other public and private organizations (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Other attempts at workforce enumeration have defined the public health workforce by the institution they are employed at or their occupational classification (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eUtilizing these approaches, there have been a handful of attempts at mapping the public health workforce at a national level through surveys, reviews of routine data, and other data collection techniques. In the United Kingdom, the Centre for Workforce Intelligence conducted a mapping of the public health workforce in England to guide policy decisions for workforce planning (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The methodology reviewed the literature and estimated the numbers of workers based on administrative records, primarily assessing workforce distribution and skills (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In the United States, a nationally representative survey of public health employees, the Public Health Workforce Interests and Needs Survey (PH WINS), has been conducted three times. The survey has captured workforce demographics, characteristics, training needs, retention metrics, and engagement \u0026amp; satisfaction (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Other studies have sought to enumerate the workforce (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), identify their training needs (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), and identify challenges faced by the workforce (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). A study by Bjegovic-Mikanovic et al. synthesized qualitative data from workforce development success stories reported by the South-Eastern Europe Health Network (SEEHN) to share a high-level view of who the public health workforce is, and the type of essential public health functions performed by the workforce (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In 2004, a study in the country of Georgia collected data on public health workers’ demographics, employment history, education, and on-the-job training, as well as opinions on HR management practices and policies and funding levels in the municipalities. The methodology included conducting a survey of directors and one employee from 30 randomly selected municipal public health centers and Focus Group Discussions among local public health professionals, center directors, and policymakers (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eGovernment leadership in Georgia identified workforce assessment as a priority based on needs identified during the COVID-19 response. The public health system in Georgia has undergone considerable restructuring and reforms over the years, particularly since the dissolution of the Soviet Union in 1991 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The country established new public health infrastructures and shifted focus from the sanitary-epidemiological service model to a more holistic approach to public health (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The apex agency for public health in the country, the National Center of Disease Control and Public Health (NCDC), was established in 1996. The NCDC oversees all essential public health functions within the country and sets standards and regulations for public health and biosecurity (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). It also manages and coordinates regional public health divisions. NCDC is supported by 65 municipal public health centers (MPHCs) spread across 11 administrative regions (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The MPHCs deliver public health services at the local level through various frontline public health workers. The employees across NCDC, its regional units, and the MPHCs constitute the core public health workforce in the country. Changes in the public health infrastructure, evolving public health needs, and the impact of the COVID-19 pandemic accentuate the need for workforce assessment.\u003c/p\u003e\u003cp\u003eOur study aimed to map the existing core public health workforce in Georgia, assessing workforce composition, demographics, workforce distribution by job function and geography, and levels of satisfaction and workforce engagement. This study was conducted to inform the development of a public health workforce strategy for the country and advance Georgia’s capability to perform essential public health functions and prevent, detect, and respond to disease threats.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eAim and Setting of the Study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe conducted a public health workforce survey in Georgia between June and September 2023. The study population included public health professionals in Georgia employed at the central and regional units of the NCDC and in 65 MPHCs distributed across 11 regions in the country. The survey excluded personnel in the Department of Technical Support and the Legal Department in NCDC, as well as drivers, janitors, and administrative assistants across NCDC and MPHCs who were determined to be support staff rather than core public health workers. The survey respondents included both permanent employees and employees on contract. The survey was administered to 390 of 446 employees in NCDC central and regional offices; the remaining staff classified as support personnel and therefore excluded. For the MPHCs, the survey was administered to 734 of 974 employees, excluding support staff.\u003c/p\u003e\u003cp\u003eAn organogram of the NCDC outlining the departments and divisions is included as additional material-1.\u003c/p\u003e\u003cp\u003e\u003cb\u003eQuestionnaire Development and Survey Process\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe survey was developed by the Johns Hopkins University team and refined based on feedback from workforce experts in NCDC Georgia and the US Centers for Disease Control and Prevention’s (CDC) country office in Georgia. The instrument drew upon existing public health workforce surveys, including the PHWINS (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), the Council on Linkages Public Health Workers Survey Instrument (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), and other validated workforce engagement questions (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The job program area classification was informed by the PHWINS classification conducted in the United States to characterize employees working in State Health Agencies and was refined for contextual relevance (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Most of the questions in the survey were closed questions, but a few questions offered opportunities for explanation.\u003c/p\u003e\u003cp\u003eThe survey (additional material 2) collected data on workforce demographics, including name, age, sex, work location, work unit, position, nature of employment, and hours worked. It also included fields on education level and focus area, as well as participation in on-the-job training. Employees were asked to indicate the percentage of time spent across different program areas and job functions, and if they held any additional positions. A section of the survey included questions on career progression within the organization. Respondents were asked to rate their job satisfaction level on a scale of 1 to 5, (where (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) is extremely dissatisfied and (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) is extremely satisfied) with different aspects of work, including pay and benefits, job duties, work culture (working hours, supervisory support, acknowledgment), and job security. Workforce engagement was also assessed by asking questions about the three most important reasons for joining and staying at the organization. The final section of the survey included questions on performance review, employees’ sense of being supported, and plans to retire.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSurvey Administration\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe survey was conducted by the NCDC leadership in English and Georgian and administered online using Qualtrics. For NCDC staff, an individualized survey link was generated through Qualtrics and emailed to all participants. In the case of MPHCs, a survey link was sent to the municipal center head, and s/he circulated it to the intended recipients as there was no central database with emails for all relevant staff. The survey was open from June 8, 2023, to September 29, 2023, and 4 rounds of follow-up were conducted. For NCDC employees, two auto reminders were sent through Qualtrics, and the head of Continuing Professional Development sent follow-up email reminders after that. For MPHC employees, the head of the unit followed up through email to increase the response rate.\u003c/p\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eSurvey responses with less than 40% completion were considered incomplete and removed from the data set, as were any duplicate responses. Open fields were translated from Georgian to English using Google Translate, and a sample of these translations was reviewed by a team member fluent in both Georgian and English to ensure accuracy. Such open fields were also cleaned through a manual review, correcting misspellings and typos. In some cases, open fields were converted into categories of responses to allow easier analysis. The dataset was checked for outliers and erroneous entries in numerical fields (e.g., age, monthly salary, number of hours worked), and these errors were excluded from data analysis. The public health workforce distribution analysis was conducted using the 2023 Georgia population estimates published by the National Statistics Office of Georgia (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eStatistical analysis was conducted using R Studio Version − 2023.09.1 + 494 and Microsoft Excel.\u003c/p\u003e\u003cp\u003e Findings were presented to and discussed with local stakeholders to verify key results and enhance interpretation.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe overall response rate of the survey was 81.3%; 914 responses were received out of 1124 public health employees approached. A total of 272 responses were received from the NCDC and regional NCDC centers, resulting in a response rate of 69.7%. The response rate for municipal centers was 87.5%. Response rates by NCDC departments and MPHC regions are included as additional material 3 and additional material 4.\u003c/p\u003e\u003cp\u003e\u003cem\u003eDistribution of public health workers\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn NCDC, 18.2% of the workforce is assigned to divisions within the Lugar Center for Public Health Research, the reference laboratory for public health in Georgia. Around 10.0% of employees work in the Communicable Diseases Department, 5.6% in Non-Communicable Diseases, 4.9% in the Department of Medical Statistics, and 1.5% in the Environmental Health Department. The total core public health workforce in the finance, administration, public relations, and quality control divisions accounts for 7.5%. A very small percentage (1.3%) are employed in the Risk Preparedness Division and the Division of Continuing Professional Training and Development. The Department of Public Health State Programs Central and Regional Management within NCDC provides direct support to the MPHCs through nine regional offices, where 22.3% of employees work. A significant proportion (28.7%) of NCDC employees are engaged in state programs, which are vertical programs funded by the state budget and administered by the NCDC. These programs are focused on domains such as HIV/AIDS, COVID-19, hepatitis, tuberculosis, blood safety, and disease prevention. At NCDC, 78.7% of staff are in permanent positions.\u003c/p\u003e\u003cp\u003eAt the local level, the density of the public health workforce in municipal units varies from 9 to 114 workers per 100,000 population (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A higher density of public health workers is seen in mountainous regions such as Svaneti. The workforce across most municipal centers except two (Adjara and Tbilisi) have similar key positions. However, the number of employees working in these positions varies and is not correlated with the population served. Across the nation there are 30.1 core public health workers per 100,000 population.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of public health employees\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMPHC Region\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePopulation of Region\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCore Public Health Workforce\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePublic health workers per 100000 people\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdjara*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e361,411\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGuria*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e104,338\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImereti*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e463,068\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e153\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKakheti*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e306,216\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKvemo Kartli\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e442,771\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMtskheta-tianeti*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e93,253\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRacha/Kvemo Svaneti*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27,120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e114.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSamegrelo/Zemo Svaneti*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e299,290\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e115\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSamtskhe-Javakheti*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e147,352\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShida Kartli*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e249,829\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTbilisi**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1,241,709\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNCDC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003en/a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e390\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003en/a\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNational\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,736,357\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1124\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Regions with regional NCDC offices\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e**Tbilisi also houses the main NCDC offices and benefits from these national level employees\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eKey positions at MPHCs include epidemiologists who are responsible for disease surveillance and preventive care services (20.8% of MPHC public health workforce); employees in immunization programs (11.7%); medical-statistical informaticians (7.6%); preventionist/prophylactic doctors (7.6%); parasitologists (5.6%); entomologists (5.0%); lab and other assistants (10.2%); there are several other positions at the MPHCs that make up a smaller proportion of the workforce. Most (84.4%) of the MPHC employees are in permanent positions.\u003c/p\u003e\u003cp\u003e\u003cem\u003eWorkforce Characteristics\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHalf of the workforce is above the age of 48 in NCDC and 56 in MPHCs. The mean years of service for NCDC employees is 14.9 years, and for MPHC employees is 18.0 years. Despite long tenures within each organization, only 33.3% of NCDC and 10.5% of MPHC staff have ever received a promotion. On average, fewer than 20 employees join NCDC and the MPHCs annually. Hiring is usually driven by organizational restructuring or increased public health needs, such as during the COVID-19 pandemic. There were surges in recruitment associated with the NCDC establishment (1996), the public health system reorganization (2007), the establishment of the Lugar Center (2012), and the COVID-19 pandemic (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe workforce is predominantly female, with 81.6% of the employees at NCDC and 90.3% at MPHCs being women.\u003c/p\u003e\u003cp\u003eAt the time of the survey, the median salaries for key positions at NCDC ranged from 750 Georgian Lari (GEL) (approximately 277 USD) per month to 2420 GEL (893 USD) per month. For MPHCs, median salaries were between 484 GEL (179 USD) per month and 1611 GEL (594 USD) per month. Among MPHC employees, we observed significant regional differences in salary for people working in the same position. The salary in some regions was half that of others.\u003c/p\u003e\u003cp\u003e\u003cem\u003eEducational background and qualifications of public health professionals\u003c/em\u003e\u003c/p\u003e\u003cp\u003ePublic health employees in Georgia have robust pre-service education (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Most NCDC employees have a master's degree or higher, and more than half of the employees with master's and bachelor's degrees specialized in public health or medicine. In MPHCs, one-quarter of staff have master's degrees, and a similar proportion have medical degrees attained through a single cycle program (programs that lasted for five years or more and issued 'specialist' diplomas upon graduation) before 1994 (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). MPHC employees' domain of education showed a similar trend to that of NCDC.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of Public Health Workforce by Educational Qualification\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducational Qualification\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNCDC staff\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMunicipal staff\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDoctoral Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.7% (n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.5% (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMasters' Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44.5% (n\u0026thinsp;=\u0026thinsp;121)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.2% (n\u0026thinsp;=\u0026thinsp;162)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOne (single)-cycle program (Medical Doctors, Dentists) or any other not specified University degree (e.g., graduates before 1994)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15.8% (n\u0026thinsp;=\u0026thinsp;43)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.3% (n\u0026thinsp;=\u0026thinsp;156)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBachelor's Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16.9% (n\u0026thinsp;=\u0026thinsp;46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.9% (n\u0026thinsp;=\u0026thinsp;153)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpecialized Secondary (\"Technicum\")/college (5th level certificate for recent graduates, e.g., Nursing Training)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11.8% (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.9% n\u0026thinsp;=\u0026thinsp;134)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh School or Professional (vocational) school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.4% (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.3% (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eContinuing Professional Development\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAmong survey respondents, 79.7% of NCDC employees and 80.2% of MPHC employees reported participating in some form of on-the-job training since assuming their positions. Most training opportunities focused on COVID-19, contract tracing, epidemic surveillance and response, and immunization. The frequency of participation in training differed between departments. Within departments at the NCDC, recent training participation was evenly distributed among key positions. Participation in training by cadres reflected a higher median age among trainees.\u003c/p\u003e\u003cp\u003e\u003cem\u003eTime spent across program areas\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn NCDC, the largest share of surveyed employees\u0026rsquo; time is spent on administrative program areas (21.9%) and public health surveillance and response (21.1%). This is followed by communicable disease management (19%), data collection, management, monitoring and evaluation (8.1%), emergency management, including the workforce engaged in COVID-19 response (6.1%), and immunization (5.3%). In comparison, NCDs (4.1%) and health promotion (2.8%) have less dedicated employee time. Less than 2% of the effort is spent on workforce development, clinical services, and policy and legislation development. The program areas where MPHC employees spend most of their time are communicable disease management (25.3%), administration (16.3%), immunization (14.9%), and emergency response, including COVID-19 (8.6%). Non-communicable diseases (2.3%), injury prevention (2.4%), workforce development (0.2%), and policy and legislation (0.1%) have a lower proportion of dedicated workforce time. The distribution of employee effort by program area is depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eWithin these program areas, 40.8% of employee effort at NCDC goes to program implementation, and the second highest allocation of time goes to research (21.8%). A similar distribution was seen at MPHCs, where 43.0% of time goes towards program implementation, and 16.6% is dedicated to research.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePerceptions of job satisfaction, engagement, and motivation\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAs Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows, most respondents had relatively high job satisfaction. It is notable that the two items receiving the lowest scores both for NCDC and MPHC staff were (i) pay and benefits and (ii) career progression. On average, satisfaction appeared to be greater among MPHC staff than NCDC staff.\u003c/p\u003e\u003cp\u003eWe found no correlation between age and satisfaction for either NCDC or MPHC employees. Satisfaction with work culture was higher among employees who received some kind of performance review. Employees who had been promoted at some point expressed higher satisfaction with career progression.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eRespondents were also asked to state their level of agreement with a series of statements concerning job motivation. The results presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e are positive overall, but for both NCDC and Municipal staff, the lowest scoring items were related to training received on the job and the extent to which this met their needs.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMean Motivation Scores for NCDC and MPHC employees\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eMean Score\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNCDC staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMunicipal staff\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMy job is meaningful, and I feel a sense of pride in doing my job\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.58\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall, the training I received on the job meets my needs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI feel appreciated and supported by the organization that I work for\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI feel appreciated and supported by my supervisor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eRespondents were also asked to identify from a list of options the three top reasons for staying in their jobs. For NCDC staff, the most frequently cited reasons were challenging work, a sense of mission, and satisfaction with their supervisor. For MPHC staff, the most common reasons were job satisfaction, satisfaction with their supervisor, and a sense of mission. Very few respondents cited a lack of opportunity elsewhere. Reasons to stay in the job didn't show any specific patterns when reviewed by age groups. The most important reason for joining the organization for both NCDC and MPHC employees was their interest in job functions, followed by the reputation of the organization. Around half of NCDC employees and 70.6% of MPHC employees reported receiving some form of performance feedback, and overall, they found these useful. However, there is no formal performance review process at NCDC or in the municipal offices, except at the Lugar Center at NCDC.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSurvey findings suggest many positive factors: the current workforce in Georgia is stable as most of the employees are in permanent positions; the workforce is well-trained in terms of pre-service education; and the longer tenure of employees suggests a wealth of knowledge gained on the job. Furthermore, the public health workforce appears satisfied and finds substantial intrinsic motivation in their work.\u003c/p\u003e\u003cp\u003eThere have been very few other public health workforce surveys in middle-income countries, so it is difficult to compare results, however, some of the findings from this survey align with what has been found in high-income countries. For example, Sellers et al. found that the state public health workforce in the US is also heavily female (72%) and has a median age of 50 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Similarly, Robin et al. found that 81% of local public health workers were female and also trended older (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). This compares to a median age of 48 years and 80% female at NCDC and 56 years and 90% female at MPHCs in Georgia. In contrast to the US, where most public health workers had been in their positions for 5 years or less (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), public health workers in Georgia have had long tenures within their organization and limited career mobility.\u003c/p\u003e\u003cp\u003eThe core public health workforce density of 30.1 employees per 100,000 population in Georgia is lower than other countries in the region, such as Poland (44.7), Moldova (57.1), and Slovenia (58.0), and falls significantly short of high-income countries such as Switzerland (102.6) and the United States (104.2) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). It is important to note that the definition of public health workforce across countries in these studies is not consistent, making comparisons difficult. However, the assessment of the public health workforce in Poland included employees working across government public health agencies and local health units, similar to our study (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWe found substantial variation in the density of municipal public health workers across regions within the country, which was difficult to explain. An earlier study in Georgia also noted the unequal distribution of public health workers but observed a concentration of such workers in urban rather than rural areas (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Some explanatory factors that we considered, such as the presence of an NCDC regional office, which might substitute for MPHC staff, or MPHCs with a higher density of staffing having an older workforce (who were disinclined to retire), were not supported by the data. The particularly low workforce density in Adjara is likely explained by a different staffing model in this autonomous region, where there is far greater centralization of public health staff, which may present a more efficient model for the country to consider in the future. Otherwise, we believe regional variations may be due to idiosyncratic staffing practices within MPHCs that could be addressed through clearer central guidelines on MPHC staffing. Indeed, since these survey findings were presented, the Ministry and NCDC have moved towards issuing such guidance.\u003c/p\u003e\u003cp\u003eBogaert et al. reported that only 19% of state health employees in the US had a degree in a public health domain at any educational level based on the PHWINS (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). A significantly higher percentage (29%) of Georgian public health employees have received a degree in specific public health domains or preventative medicine, and another 11% are medical doctors. Also, 53% of the workforce in Georgia have a master's degree compared to 31% reported by Bogaert et al in the US (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). However, this comparison is slightly nuanced due to the structure of the education system in Georgia until 1994, when single-cycle programs were offered and considered equivalent to a master's degree. Thereafter, these degrees were split into a two-tier system - a four-year bachelor's and a two-year master's (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Nonetheless, this observation of a more highly educated workforce than other countries aligns with other studies on the general health workforce that note that Georgia has a high availability of qualified physicians, even compared to other countries in the region (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePublic health workforce salaries in Georgia are relatively low compared to other similar roles within the country. The National Statistics Office in Georgia reported that the average monthly salary for public administration and social security workers is around GEL 1,823 (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), approximately twice that of many key public health positions. Our discussions with universities offering public health courses suggested that lower salaries compared to private sector employees act as a barrier to graduates opting for government public health positions. Both satisfaction and motivation among Georgian public health workers appeared high despite limited prospects for promotion and relatively low pay. Other studies of health worker motivation in Georgia have also found this (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) and noted that factors such as good relationships with supervisors, and a sense of meaning in work are key. However, it should be noted that US studies have shown high job satisfaction but also a high intent to leave (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Since the survey was employer-led, we avoided questions about employees' intention to leave, but it is clear that turnover among public health workers in Georgia is very low.\u003c/p\u003e\u003cp\u003eWe faced challenges in collecting accurate data on training conducted during the past two years, but workers' responses suggest that improved training opportunities may enhance workforce motivation. This resonates with an earlier study that also concluded that improved opportunities for continuing education in the public health workforce were key to workforce development (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). A higher median age among trainees who received training opportunities indicates that younger members of the workforce who might be able to apply skills for a longer period may need additional targeted training interventions to address their needs and support long-term career development goals.\u003c/p\u003e\u003cp\u003eThis survey indicates several areas in which NCDC may intervene to strengthen the public health workforce: most notable is a need to recruit public health workers to address areas of emerging importance such as environmental health and health promotion (especially for non-communicable diseases), providing competitive salaries to attract a younger workforce, and strengthening the array of training opportunities offered. This profile of Georgia\u0026rsquo;s public health workforce allows the government to understand better its capabilities to prevent, detect, and respond to public health threats and prepare for future epidemics and pandemics. Understanding the training needs of the public health workforce would also allow the government and partners to tailor and provide appropriate training opportunities targeting specific capacity development needs, building accountability and career pathways, and being more effective and efficient with their resources.\u003c/p\u003e\u003cp\u003eThe government is in the process of approving a new public health workforce strategy that adopts many of these recommendations. Salaries for the public health workforce increased by approximately 10% for each cadre in early 2024 after this survey was conducted, and several other changes are also underway.\u003c/p\u003e\u003cp\u003e\u003cem\u003eLimitations of the study\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis survey was sponsored and administered by NCDC, and while respondents were assured that their responses would remain anonymous, there may nonetheless be a social desirability bias in responses, with participants sometimes providing information that their employer would expect and not revealing more negative attitudes. We also recognize that by focusing on the core public health workforce, our survey failed to cover many health workers who contribute to public health as part of their jobs (albeit not their primary focus). Accordingly, the survey provides an incomplete picture of how public health functions are carried out in Georgia. Despite this, we believe this study provides important information about issues facing the core public health workforce in the country.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis is the first national survey of Georgia's core public health workforce. Survey findings present a comprehensive overview of workforce distribution by job function, geography, key characteristics, and their level of satisfaction, motivation, and engagement. The insights gained are critical in identifying and addressing workforce planning and development bottlenecks. First, understanding how the current workforce spends their time aids in aligning workforce planning to public health needs and the country's disease profile. Second, the findings indicate the importance of accelerating investment in training, especially for younger members of the workforce. Third, we found relatively low salary levels and unexplained variation in salaries, suggesting that efforts to increase and standardize salaries may be warranted to promote even-handedness and improve motivation.\u003c/p\u003e\u003cp\u003eFinally, this initial effort to profile the public health workforce could guide similar assessments in the future in Georgia, providing an opportunity to track how human resource policies are affecting the workforce. Georgia's experience could also serve as a reference to other post-Soviet countries in the region as they advance their public health workforce to address country and regional priorities. These efforts contribute to improving health security and pandemic preparedness. Similar assessments of the public health workforce elsewhere could help provide an evidence-based approach to workforce planning and development.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eIf abbreviations are used in the text, they should be defined in the text at first use, and a list of abbreviations should be provided.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAbbreviation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 474px;\"\u003e\n \u003cp\u003eMeaning\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eEPHFs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 474px;\"\u003e\n \u003cp\u003eEssential Public Health Functions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eFETP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 474px;\"\u003e\n \u003cp\u003eField Epidemiology Training Program\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eFTEs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 474px;\"\u003e\n \u003cp\u003eFull-Time Equivalents\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eHRIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 474px;\"\u003e\n \u003cp\u003eHuman Resource Information System\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eJHU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 474px;\"\u003e\n \u003cp\u003eJohns Hopkins University\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eMoH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 474px;\"\u003e\n \u003cp\u003eMinistry of Internally Displaced Persons from the Occupied Territories, Health, Labour and Social Affairs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eMPHCs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 474px;\"\u003e\n \u003cp\u003eMunicipal Public Health Centers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eNCDC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 474px;\"\u003e\n \u003cp\u003eNational Center for Disease Control and Public Health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eSEEHN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 474px;\"\u003e\n \u003cp\u003eSouth-Eastern Europe Health Network\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eUS CDC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 474px;\"\u003e\n \u003cp\u003eUnited States Centers for Disease Control and Prevention\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003eAll manuscripts must contain the following sections under the heading 'Declarations':\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eEthics approval and consent to participate.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eEthical clearance was received from the Institutional Review Board (IRB) of the National Center for Disease Control and Public Health of Georgia (Ref: IRB # 2023-037, Dated - June 2, 2023). Written informed consent was incorporated at the beginning of the online survey, requiring participant acknowledgment before proceeding with the survey. Consent language and process were approved by the IRB. Data management was conducted as per IRB approvals. All scientific data collected was preserved in a password-protected Microsoft One drive database provided by JHSPH IT. The database was only available to study team members. The survey was administered and collected through Johns Hopkins Qualtrics and was available to the study team through JHU institutional login details. \u0026nbsp; Identifiers such as names, email addresses, and phone numbers were deleted from the survey data before data analysis.\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eConsent for publication - Not applicable.\u003c/li\u003e\n \u003cli\u003eAvailability of data and materials - The datasets generated and/or analyzed during the current study are not publicly available to protect participant privacy.\u003c/li\u003e\n \u003cli\u003eCompeting interests - The authors declare no competing interests.\u003c/li\u003e\n \u003cli\u003eFunding – Funding for this research was provided under a grant by the US CDC to the Johns Hopkins School of Public Health team.\u003c/li\u003e\n \u003cli\u003eAuthors' contributions\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSurvey Tool Development – S.R., E.C developed the first draft of the survey tool. S.B. and B.A reviewed and revised the tool. E.G and T.S. reviewed and shared inputs for tool contextualization and improvement.\u003c/p\u003e\n\u003cp\u003eSurvey Administration –\u0026nbsp;E.G., led the survey administration with the support of E.C and S.R.\u003c/p\u003e\n\u003cp\u003eManuscript writing – S.R. wrote the first draft of the manuscript, S.B., and B.A. reviewed and shared significant inputs to improve the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAcknowledgements –This work was conducted with support from the US CDC NPHI program under\u0026nbsp;Award No. NU2HGH000014.\u003c/li\u003e\n \u003cli\u003eAuthors' information (optional)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eRequired Disclaimer:\u003c/p\u003e\n\u003cp\u003eThe findings and conclusions in this report are those of the author(s) and do not necessarily represent \u0026nbsp;the official position of [the U.S. Centers for Disease Control and Prevention. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWoltring CS, Novick LF. Public health workforce: infrastructure\u0026apos;s keystone. J Public Health Manag Pract. 2003;9(6):438-9.\u003c/li\u003e\n\u003cli\u003eOtok R, Richardson E, Czabanowska K, Middleton J. The public health workforce In: Rechel B, Jakubowski E, McKee M, Nolte E, editors. Organization and financing of public health services in Europe2018.\u003c/li\u003e\n\u003cli\u003eLichtveld MY, Cioffi JP. Public Health Workforce Development: Progress, Challenges, and Opportunities. Journal of Public Health Management and Practice. 2003;9(6):443-50.\u003c/li\u003e\n\u003cli\u003eBoniol M, Kunjumen T, Nair TS, Siyam A, Campbell J, Diallo K. The global health workforce stock and distribution in 2020 and 2030: a threat to equity and \u0026apos;universal\u0026apos; health coverage? BMJ Glob Health. 2022;7(6).\u003c/li\u003e\n\u003cli\u003eLiu JX, Goryakin Y, Maeda A, Bruckner T, Scheffler R. Global Health Workforce Labor Market Projections for 2030. Hum Resour Health. 2017;15(1):11.\u003c/li\u003e\n\u003cli\u003eMartineau T, Ozano K, Raven J, Mansour W, Bay F, Nkhoma D, et al. Improving health workforce governance: the role of multi-stakeholder coordination mechanisms and human resources for health units in ministries of health. Hum Resour Health. 2022;20(1):47.\u003c/li\u003e\n\u003cli\u003eDubois CA, Singh D. From staff-mix to skill-mix and beyond: towards a systemic approach to health workforce management. Hum Resour Health. 2009;7:87.\u003c/li\u003e\n\u003cli\u003eCollaborators GBDHRfH. Measuring the availability of human resources for health and its relationship to universal health coverage for 204 countries and territories from 1990 to 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2022;399(10341):2129-54.\u003c/li\u003e\n\u003cli\u003eMcQuide PA, Brown AN, Diallo K, Siyam A. The transition of human resources for health information systems from the MDGs into the SDGs and the post-pandemic era: reviewing the evidence from 2000 to 2022. Hum Resour Health. 2023;21(1):93.\u003c/li\u003e\n\u003cli\u003eEurope WROf. ROADMAP TO PROFESSIONALIZING THE PUBLIC HEALTH WORKFORCE IN THE EUROPEAN REGION. 2022.\u003c/li\u003e\n\u003cli\u003eGebbie K, Merrill J, Tilson HH. The public health workforce. Health Aff (Millwood). 2002;21(6):57-67.\u003c/li\u003e\n\u003cli\u003eWatts RD, Bowles DC, Ryan E, Fisher C, Li IW. No Two Workforces Are the Same: A Systematic Review of Enumerations and Definitions of Public Health Workforces. Front Public Health. 2020;8:588092.\u003c/li\u003e\n\u003cli\u003eBeck AJ, Meit M, Heffernan M, Boulton ML. Application of a Taxonomy to Characterize the Public Health Workforce. J Public Health Manag Pract. 2015;21 Suppl 6:S36-45.\u003c/li\u003e\n\u003cli\u003eIntelligence CfW. Mapping_the_core_public_health_workforce. 2014.\u003c/li\u003e\n\u003cli\u003eSellers K, Leider JP, Harper E, Castrucci BC, Bharthapudi K, Liss-Levinson R, et al. The Public Health Workforce Interests and Needs Survey: The First National Survey of State Health Agency Employees. J Public Health Manag Pract. 2015;21 Suppl 6(Suppl 6):S13-27.\u003c/li\u003e\n\u003cli\u003eHalverson PK. Ensuring a Strong Public Health Workforce for the 21st Century: Reflections on PH WINS 2017. J Public Health Manag Pract. 2019;25 Suppl 2, Public Health Workforce Interests and Needs Survey 2017(2 Suppl):S1-S3.\u003c/li\u003e\n\u003cli\u003eMerrill J, Btoush R, Gupta M, Gebbie K. A history of public health workforce enumeration. J Public Health Manag Pract. 2003;9(6):459-70.\u003c/li\u003e\n\u003cli\u003eBogaert K, Castrucci BC, Gould E, Rider N, Whang C, Corcoran E. Top Training Needs of the Governmental Public Health Workforce. J Public Health Manag Pract. 2019;25 Suppl 2, Public Health Workforce Interests and Needs Survey 2017(2 Suppl):S134-S44.\u003c/li\u003e\n\u003cli\u003eJacob RR, Baker EA, Allen P, Dodson EA, Duggan K, Fields R ea. Training needs and supports for evidence-based decision making among the public health workforce in the United States. BMC Health Services Research. 2014.\u003c/li\u003e\n\u003cli\u003eBjegovic-Mikanovic V, Santric-Milicevic M, Cichowska A, von Krauss MK, Perfilieva G, Rebac B, et al. Sustaining success: aligning the public health workforce in South-Eastern Europe with strategic public health priorities. Int J Public Health. 2018;63(5):651-62.\u003c/li\u003e\n\u003cli\u003eDjibuti M, Gotsadze G, Mataradze G, Menabde G. Human resources for health challenges of public health system reform in Georgia. Hum Resour Health. 2008;6:8.\u003c/li\u003e\n\u003cli\u003eMarina K, Charlotte K, Erica R. Trends in health systems in the former Soviet countries. In: Rechel B, Richardson E, McKee M, editors. European Observatory Health Policy Series. European Observatory Health Policy Series. Copenhagen (Denmark)2014.\u003c/li\u003e\n\u003cli\u003eGotsadze G, Chikovani I, Goguadze K, Balabanova D, McKee M. Reforming sanitary-epidemiological service in Central and Eastern Europe and the former Soviet Union: an exploratory study. BMC Public Health. 2010;10:440.\u003c/li\u003e\n\u003cli\u003eHealth LSNCfDCaP. Strategic Plan 2018-2022 [Available from: https://www.ncdc.ge/#/pages/file/22705b5c-31b7-40f4-a0f7-163796f933c6.\u003c/li\u003e\n\u003cli\u003eVerulava T, Jorbenadze A. \u0026quot;Development of Public Health in Georgia: Challenges and Policy Issues\u0026quot;. Archives of the Balkan Medical Union. 2022;57(2):179-84.\u003c/li\u003e\n\u003cli\u003eGamkrelidze A, Atun, Rifat, Gotsadze, George. et al. . Health Care Systems in Transition. 2002.\u003c/li\u003e\n\u003cli\u003eLeider JP, Bharthapudi K, Pineau V, Liu L, Harper E. The Methods Behind PH WINS. J Public Health Manag Pract. 2015;21 Suppl 6(Suppl 6):S28-35.\u003c/li\u003e\n\u003cli\u003eFoundation PH. Council on Linkages Public Health Workers Survey Instrument [Available from: https://www.phf.org/resourcestools/Documents/Public_Health_Worker_Survey.pdf.\u003c/li\u003e\n\u003cli\u003eWiley JW. Using Employee Opinions about Organizational Performance to Enhance Employee Engagement Surveys: Model Building And Validation. HR People \u0026amp; Strategy. 2014.\u003c/li\u003e\n\u003cli\u003eGEORGIA NSOO. NUMBER OF POPULATION 2023 [Available from: https://www.geostat.ge/media/53004/Number-of-Population-as-of-January-1%2C-2023.pdf.\u003c/li\u003e\n\u003cli\u003eL M, N G. The many faces of research assessment: Case of independent Georgia. Journal of Research and Innovation in Higher Education. 2023.\u003c/li\u003e\n\u003cli\u003eRobin N, Castrucci BC, McGinty MD, Edmiston A, Bogaert K. The First Nationally Representative Benchmark of the Local Governmental Public Health Workforce: Findings From the 2017 Public Health Workforce Interests and Needs Survey. J Public Health Manag Pract. 2019;25 Suppl 2, Public Health Workforce Interests and Needs Survey 2017(2 Suppl):S26-S37.\u003c/li\u003e\n\u003cli\u003eOrganisation WH. Organization and financing of public health services in Europe Country Reports2018.\u003c/li\u003e\n\u003cli\u003eGEORGIA NSOO. Employment and Wages 2023 [Available from: https://www.geostat.ge/en/modules/categories/39/wages.\u003c/li\u003e\n\u003cli\u003eFranco LM, Bennett S, Kanfer R, Stubblebine P. Determinants and consequences of health worker motivation in hospitals in Jordan and Georgia. Soc Sci Med. 2004;58(2):343-55.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"human-resources-for-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hrhe","sideBox":"Learn more about [Human Resources for Health](http://human-resources-health.biomedcentral.com)","snPcode":"12960","submissionUrl":"https://submission.nature.com/new-submission/12960/3","title":"Human Resources for Health","twitterHandle":"@HRH_Journal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Public Health Workforce, Workforce Development, Workforce Survey","lastPublishedDoi":"10.21203/rs.3.rs-7041629/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7041629/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eA well-functioning public health system relies on a robust public health workforce. Comprehensive data on the workforce, such as number, distribution, and key characteristics, is crucial for evidence-based workforce planning and development. However, very few comprehensive public health workforce assessments exist, especially in low- and middle-income countries. Public health reforms over the years and needs identified during the COVID-19 pandemic prompted this assessment in Georgia.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eA survey of the core public health workforce, including employees at central and regional units of the National Center for Disease Control and municipal public health centers, was conducted online between June and September 2023. The survey collected data on workforce demographics, education, on-the-job training, and time spent across different program areas and job functions. The survey also included questions on career progression within the organization, job satisfaction, and motivation.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eThe response rate to the survey was 81.3%. Findings showed that the median age is 48 for the NCDC workforce and 56 for the MPHCs. Over 80% of NCDC and 90% of MPHC employees are women. Employees have robust pre-service education, with more than half specializing in the public health domain. The mean years of service are 14.9 for NCDC employees and 18.0 for MPHC employees, but career mobility is limited, and salary structures vary by region. Despite long tenures, only 33.3% of NCDC and 10.5% of MPHC staff have ever been promoted. At NCDC, the largest share of employee time is spent on administrative program areas, and surveillance and response, while MPHC employees primarily focus on communicable disease management, administration, and immunization. Participation in training is limited, with employees in key positions having better access to training. The workforce reports reasonable satisfaction and finds substantial intrinsic motivation in their work.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eThe insights gained from this study are pivotal in identifying workforce planning and development bottlenecks in Georgia and developing targeted strategies. Key areas for intervention include recruiting workers to meet emerging public health needs, providing competitive salaries to attract a younger workforce, and strengthening training offerings. This effort to profile the public health workforce could guide similar assessments in the future and in other countries to prevent, detect, and respond to public health threats.\u003c/p\u003e","manuscriptTitle":"Optimizing Georgia’s Public Health Workforce: A Study on Demographics, Engagement, and Capacity Building","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-19 15:39:00","doi":"10.21203/rs.3.rs-7041629/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-15T11:36:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-13T01:17:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"106415305700843286242717264651430435239","date":"2026-02-26T02:03:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-01T12:48:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"256607021761665176248942510944843762208","date":"2025-08-26T01:30:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-12T04:47:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-04T11:41:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-04T11:40:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"Human Resources for Health","date":"2025-07-03T22:45:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"human-resources-for-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hrhe","sideBox":"Learn more about [Human Resources for Health](http://human-resources-health.biomedcentral.com)","snPcode":"12960","submissionUrl":"https://submission.nature.com/new-submission/12960/3","title":"Human Resources for Health","twitterHandle":"@HRH_Journal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"65c5855c-8dfd-4894-8384-19bc6df236b4","owner":[],"postedDate":"August 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T10:00:50+00:00","versionOfRecord":{"articleIdentity":"rs-7041629","link":"https://doi.org/10.1186/s12960-026-01072-0","journal":{"identity":"human-resources-for-health","isVorOnly":false,"title":"Human Resources for Health"},"publishedOn":"2026-05-02 15:57:29","publishedOnDateReadable":"May 2nd, 2026"},"versionCreatedAt":"2025-08-19 15:39:00","video":"","vorDoi":"10.1186/s12960-026-01072-0","vorDoiUrl":"https://doi.org/10.1186/s12960-026-01072-0","workflowStages":[]},"version":"v1","identity":"rs-7041629","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7041629","identity":"rs-7041629","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}