synthesis paper-health workforce.pdf

18th Board Meeting

25-26 February 2015

GHWA Board Working Group - Agenda Item 3.1

AGENDA ITEM 3.1: GHWA Board Working Group. Progress.

Background

At the 16 th

Board Meeting (November 2014) the Board determined to commence a global consultation on a future, strategic framework for HRH.

BM16/2013/8/DP06: The Board appointed a Working Group comprised of representation from

World Bank, AfDB, USAID, ICM, China, UK (DFID) ,WHO, Brazil and NORAD to develop a draft HRH Strategic Framework for the next 15-20 years, and propose a potential role of GHWA within that strategy.

A working group was formed to coordinate and oversee a global consultation to identify key elements of a long-term strategic framework for human resources for health in the post-2015 period. The process established eight thematic working groups to capture evidence and present recommendations.

The preliminary drafts of the papers were discussed at the 17 th GHWA Board meeting in July 2014.

In May 2014, the World Health Assembly endorsed (WHA 67.24) the “Recife Political

Declaration on Human Resources for Health: renewed commitments towards universal health coverage”, adopted at the Third Global Forum on Human Resources for Health. The WHA resolution requests the WHO Director General to “develop and submit a new global strategy for human resources for health for consideration by the Sixty-ninth World Health Assembly” in 2016.

The mandate given to the WHO builds upon, reinforces and takes forward efforts coordinated by

GHWA. A process was therefore agreed for the GHWA evidence to be finalized by February 2015 to inform the development of the Global Strategy on HRH through the WHO governance processes.

Update

Since the 17 th

BM, the papers were presented and discussed at the 3rd Global Symposium on

Health Systems Research in Cape Town (October 2014). A public hearing on the draft thematic papers was held between 24 September and 30 November 2014; collective submissions were also made as a result of consultation opportunities held at numerous conferences in the autumn of 2014.

The Secretariat has produced an analytical synthesis of the thematic papers and the comments received on them, and held a further public consultation process, from 21 to 31 January 2015, on the synthesis document itself. The Board Working Group has reviewed and agreed the draft submitted to the Board for review and discussion.

Late comments from the public consultation process have not yet been included in the draft.

The Board is invited to:

I. Review and endorse the synthesis paper as reflective of the position of the GHWA Board

II. Agree text for inclusion in the 18 th

BM statement.

Agenda item for: discussion / endorsement:

Document/s attached:

3.1a Synthesis paper

Global Health Workforce Alliance

Synthesis paper of the thematic working groups (draft for consultation)

Health workforce 2030: towards a global strategy on human resources for health

Contents

Abbreviations

Background

1. A strategic vision for the health workforce in the 21st century

2. Learning from the past, looking to the future

2.1 Why invest in human resources for health

2.2 Taking stock of experience to date

2.3 Envisioning future scenarios and understanding trends

2.4 Policy frameworks and underlying principles provide solid foundations

3. The contemporary evidence for a 21st century health workforce agenda

3.1 The future for health labour markets

3.2 Data and evidence for sound planning and decision-making

3.3 Leadership and governance for effective stewardship of HRH development

3.4 Mobilizing financial resources and securing their strategic use

3.5 Transforming education

3.6 Deploying and keeping health workers where they are needed

3.7 Maximizing quality and performance of existing health workers

3.8 Promoting self-reliance in communities

3.9 Harnessing private sector (for-profit and not-for-profit) capacity for public sector goals

4. Estimating resource implications of the global health workforce agenda

5. The need for a fit-for-purpose global architecture for HRH

6. Call to action

7. Accountability framework

References

Figures

Figure 1. Policy levers to shape health labour markets

Figure 2. Framework for improving health worker performance and productivity

Table

Table 1. Estimated health worker deficit by region and income

Boxes

Box 1. Building institutions for HRH development in fragile States and disrupted contexts . 16

Box 2. Harnessing opportunities from technology innovations

Box 3. The global health labour market and international migration of health workers

Abbreviations

GDP gross domestic product

GHWA Global Health Workforce Alliance

HRH human resources for health

ICT information and communications technology

ILO International Labour Organization

ISCO International Standard Classification of Occupations

OECD Organisation of Economic Co-operation and Development

WHO World Health Organization

Background

In 2013 the Board of the Global Health Workforce Alliance (GHWA) decided to facilitate the development of forward-looking strategic thinking on human resources for health (HRH). This synthesis paper was developed as a result of a broad-based consultation process, and it captures the evidence and recommendations from the papers produced by eight thematic working groups (1).

The preliminary drafts of the papers were discussed at the GHWA Board meeting in July 2014, and presented at the third Global Symposium on Health Systems Research in Cape Town, South

Africa (October 2014). A public hearing on the draft thematic papers was held between 24

September and 30 November 2014, as a result of which over 20 submissions were received from international agencies, professional associations, networks and civil society groups; collective submissions were also made as a result of consultation opportunities held at conferences. The

GHWA Secretariat produced this analytical synthesis of the thematic papers and the comments received on them, and will present it, after a further public consultation process, to the GHWA

Board for consideration at its eighteenth meeting in February 2015.

The Board and Secretariat express their appreciation for the contributions of more than 150 individuals who led and supported the development of the evidence papers in the period 2013–

2014.

1. A strategic vision for the health workforce in the 21st century

1. The health workforce will be critical to achieving health and wider development objectives in the next decades. The United Nations Secretary-General has launched a call to action to people and leaders across the world in support of a truly transformative agenda beyond 2015 in order to ensure a life of dignity for all (2).

The Board of the GHWA has risen to this challenge, recognizing that the health targets under consideration in the proposed sustainable development goals, including a renewed focus on equity and universal health coverage, will only be attained through substantive and strategic investments in HRH. The Ebola crisis has also demonstrated how global health security hinges on a fit-for-purpose health workforce and resilient public health systems.

2. The foundations for a strong and effective health workforce able to respond to the priority needs of the 21st century require matching today’s supply of professionals with the demands of tomorrow’s populations. The ongoing challenges of health workforce deficits and imbalances, prevalent in countries at all levels of socioeconomic development, combined with ageing populations and epidemiologic transformations, require the global community to reappraise and re-evaluate the effectiveness of past efforts on the health workforce, and instil these lessons in a new, contemporary agenda on HRH.

In parallel, there is an opportunity to ensure that much-needed investments in the health workforce also lead to the creation of qualified employment opportunities, in particular for women, spurring economic growth.

3. A paradigm shift is thus needed in how we plan, educate, deploy and reward health workers. Reflecting on a decade of lessons learned in health workforce development efforts, the Board of the GHWA notes that much progress has been made, but that much remains to be done to attain its original vision that “all people everywhere will have access to a skilled, motivated and supported health worker, within a robust health system”. While this vision remains as relevant today as it was when it was adopted, attaining it will require a new discourse, and a radical transformation of implementation efforts at country level, a moving:

� away from seeing health workers as a recurrent expenditure to contain, and towards recognizing health workforce investment as a strategy for the creation of employment opportunities, particularly for women, and as a driver of socioeconomic development;

� beyond fragmentation and underfunding towards an overhaul of national and global governance for HRH, laying the grounds for a substantive scaling up of public sector and international financing to meet current and future HRH needs; and

� towards a dramatic improvement in efficiency, made possible by stronger national institutions able to devise and implement more effective strategies for health workforce education, policies for a more sustainable and responsive skills mix, and improved working conditions, reward systems and career pathways for HRH.

a Throughout this document, reference to policy and actions at “country level” or at “national level” should be understood as relevant in each country in accordance with subnational and national responsibilities.

4. Better evidence will be a critical enabler for enhanced governance and accountability at national and global levels. Evidence-based planning and forecasting of workforce requirement, informed by reliable and updated health workforce information, labour market analyses, and scanning of future scenarios, will be required to inform the development and implementation of workforce strategies. Ensuring effective governance in countries, and aligning the required efforts of different sectors and constituencies in society, is critical, and requires the political will – and accountability of – heads of government. Similarly, a fit-for-purpose mechanism for global governance for HRH is needed in order to support global accountability on HRH, effectively linked with United Nations system processes and mechanisms for monitoring of universal health coverage and sustainable development goals; and to be a catalyst for and advocate of a multisectoral and multistakeholder HRH agenda.

5. We have long known what needs to be done; but we have now better evidence than ever before on how to do it. This document reflects on the contemporary evidence on what works in health workforce development across different aspects, ranging from planning and education, across management, retention, incentives and productivity; it outlines the shared understanding among all the constituencies of the GHWA for a forward-looking health workforce agenda. It is intended to inform the development of a

World Health Organization (WHO) global strategy on human resources for health, which will be considered by the sixty-ninth World Health Assembly in May 2016, and to inspire and catalyse more incisive, multisectoral action, at country level by planners and policy-makers, and at global level by the international community.

2. Learning from the past, looking to the future

2.1 Why invest in human resources for health

6. Health systems can only operate with a health workforce; improving health services coverage and health outcomes is dependent on their availability, accessibility, acceptability and quality (3–5). It has long been known that one of the best investments governments can make is ensuring its citizens are healthy (6); a large proportion of the growth in full income (factoring in also the monetary value of increased life expectancy) in low- and middle-income countries in recent decades has resulted from better health (7).

However, health priorities of the emerging post-2015 development framework – such as ending the AIDS, tuberculosis and malaria epidemics, achieving drastic reductions in maternal mortality, and ending preventable deaths of newborns and under-5 children– will remain aspirational unless accompanied by strategies involving transformational efforts on health workforce capability. Indeed, building an adequate health workforce can represent one of the “best buys” in public health, as evidenced by an estimated 16-fold return on investment of the training and deployment of midwives to community level (8). Beyond the health goals set by the international community, every nation should have the ability to protect the health of their populations and fulfil their obligations towards collective global health security envisaged in the International Health Regulations (9); this in turn requires a skilled, trained and supported health workforce (10).

7. New evidence is starting to emerge on the broader socioeconomic impacts of health workforce investments. In many high-income countries, empirical data show that health sector employment has in overall terms remained stable or grown during the recession, contributing to the resilience of national economies (11). In the past, health sector employment has largely been seen as consumption, a recurrent cost – weighing heavily on public sector budgets – to be contained. But recent analyses using global data drawn from low-, middle- and high-income countries show that health care employment has a significant growth-inducing effect on other sectors (12). This fundamental shift in our understanding, together with the expected growth in health labour markets, means that investing and supporting health care education and employment will increasingly represent a strategy for countries at all levels of socioeconomic development to create qualified jobs in the formal sector, an opportunity likely to be harnessed in particular by women due to health workforce feminization trends. Beyond its obvious role in terms of ensuring healthy lives and promoting well-being for all at all ages, investment in HRH has therefore the potential to be a driver for socioeconomic development at large, including poverty elimination, gender equality, synergies with the education agenda, and the creation of productive employment and decent work for all (13).

2.2 Taking stock of experience to date

8. In mapping a forward-looking agenda, it is critical to reflect on lessons learned from the past. The pivotal role of HRH in the attainment of health goals has long been the focus of targeted analyses: the Joint Learning Initiative (14) and the WHO World health report

2006 (15) drew specific attention to the challenges affecting low- and middle-income countries, calling for a “decade of action” on HRH. The launch of the GHWA (16), the convening of three global forums on HRH (in 2008, 2011 and 2013) (17), and the adoption in 2010 by the World Health Assembly of the WHO Global Code of Practice on the

International Recruitment of Health Personnel (18) represented key milestones of the HRH movement in the last decade, having bolstered political attention to the issue.

9. Countries at all levels of socioeconomic development face, to varying degrees, difficulties in the education, deployment, retention, and performance of their workforce (5). While a growing resource envelope is envisaged in low- and middle-income nations, many high-income countries struggle to match supply and demand of health workers under existing affordability and sustainability constraints, a trend likely to be exacerbated by ageing populations, and which is resulting in a chronic underproduction of health workers and a continued overreliance on importing foreign-trained health personnel (19). Furthermore, even in the absence of the numerical shortages found in low-and middle-income countries, evidence has emerged of large and unexpected variances in the quality of care in high-income countries, which severely affect health care outcomes and point to the need for radical improvements in the competencies and performance of health workers in these settings (20).

10. Despite significant progress, there is a need to boost political will and mobilize resources for the workforce agenda. Past efforts in health workforce development have yielded significant results: examples abound of countries that, by addressing their health workforce challenges, have improved their health outcomes (21, 22). In addition, at the aggregate level, health workforce availability is improving for the majority of countries for which data are available, although often not rapidly enough to keep pace with population growth (5). However, progress has not been fast enough, nor deep enough. The key challenge is not lack of evidence on effective interventions: it is how to mobilize political will and financial resources for the contemporary HRH agenda (23, 24).

2.3 Envisioning future scenarios and understanding trends

11. A critical challenge in health workforce development is to respond to today’s needs while anticipating tomorrow’s expectations and harnessing future opportunities. Horizon scanning exercises, taking cognizance of “big picture” trends, and the quantification of health workforce needs, demands and supply in baseline and alternative scenarios, are of paramount importance (25). An evolving epidemiologic profile and population structures are increasing the burden of noncommunicable diseases and long-term care on health systems throughout the world (26). This is accompanied by a progressive shift in the demand for patient-centred health services and personalized care (27). There are opportunities in the adoption of preventive rather than disease-driven models of care. At the same time, emerging economies are undergoing an economic transition that will increase their health resource envelope, and a demographic transition that will see hundreds of millions of potential new entrants into the active workforce. Other opportunities stem from technological innovation and the beginning of a “big data” era, characterized by a dramatic growth in the types and quantity of data collected by both patients and health workers. Big data approaches applied to better understand health worker presence, performance and larger trends will give insights into the gaps and possibilities for health workforce strengthening all the way to the facility and community level. These prospects create an unprecedented opportunity to design and implement health workforce strategies that address the equity and effective coverage gaps faced by health systems, while also unlocking economic growth potential, contributing to a convergence in health and development outcomes within a generation (7).

2.4 Policy frameworks and underlying principles provide solid foundations

12. Numerous resolutions of intergovernmental bodies and global action plans endorsed by the

United Nations in the last decade have recognized the critical importance of HRH. In the development of these recommendations, we reaffirm in particular the importance of the

Kampala Declaration and the Agenda for Global Action (28), the WHO Global Code of

Practice on the International Recruitment of Health Personnel (18), and the Recife

Declaration on Human Resources for Health (29). Relevant intergovernmental agreements, mandates, resolutions and plans of action have also been endorsed at the regional level recognizing the critical importance of HRH (30). We also take note of the United Nations

General Assembly resolution on universal health coverage, which identified the need for

“an adequate, skilled, well-trained and motivated workforce” in order to accelerate progress towards universal health coverage (31).

Furthermore, we welcome the recognition of the importance of HRH in the relevant United Nations Economic and Social Council (32), World Health Assembly (33) and International Labour Conference (34) resolutions; and, among others, in the United Nations Global Strategy for Women’s and Children’s Health

(35), the Every Newborn Action Plan (36), the Family Planning 2020 objectives (37), the

Global Plan towards the Elimination of New HIV Infections (38), the International Labour

Organization (ILO) Social Protection Floor Initiative (39), and the Global Action Plan for the Prevention and Control of Noncommunicable Diseases (40). These resolutions, political declarations and strategic documents represent a solid foundation to build upon, as they provide the mandate, framework and guidance for action on HRH and for according high priority to and recognizing the centrality of investment in HRH.

13. Several underlying principles guide both our analysis of the evidence and the development of a future vision. We are informed in our work by the belief that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being, without distinction of race, religion, political belief or economic or social condition. We recognize that governments have a duty to fulfil their citizens’ basic rights regarding social protection, including the provision of essential health care, and that, in attempting to accelerate progress towards universal health coverage, priority should be given to vulnerable groups. We acknowledge that countries are bound together by a duty of international solidarity, with an obligation to assist low-income and fragile States in mobilizing sufficient resources for adequate health workforce investments. We believe that health systems should provide services that are respectful, appropriate to needs, and responsive to patients’ sociocultural expectations, empowering and engaging them to be active participants in the health care production processes. And finally, we believe it is the right of health workers to be protected from violence and discrimination in the workplace

(41), and more generally to be allowed to operate within a positive practice environment that guarantees occupational safety and health, with adequate support by the health system.

3. The contemporary evidence for a 21st century health workforce agenda

14. The actions required to have a fit-for-purpose and fit-to-practise health workforce in the

21st century amount collectively to a paradigm shift across several dimensions of HRH governance, financing, education, deployment and management. Applying a labour market framework to the health workforce discourse helps to understand the interconnectedness of these elements and to identify relevant policy levers.

3.1 The future for health labour markets

15. Understanding national and global health labour market forces and trends is critical for developing effective health workforce plans. The demand for and the size of the global health workforce are expected to grow substantially as a consequence of population and economic growth, combined with demographic and epidemiologic transitions. Overall, these trends are accelerating the need and demand for health workers across the globe, and are compounded by an ageing of the health workforce itself. Efforts to scale up essential interventions to achieve the health-related Millennium Development Goals and universal health coverage have revealed a massive shortage of skilled health professionals in many low- and middle-income countries (15, 42). Furthermore, health workers – like all workers

– are sensitive to differences in remuneration, working conditions and career prospects;

substantive disparities in these factors create powerful market forces for migration, both within and outside national borders. This in turn can exacerbate pre-existing shortages, often with negative impact on the availability of health services for underserved communities. There are substantial mismatches in the needs of, demand for and supply of health workers both nationally and globally, leading to inequitable distribution and deployment of health workers. Efforts to address health workforce issues have tended to focus narrowly on supply-side models or needs-based projections of health workforce requirements. But effective solutions will need to align these interventions with health service priorities, and with individual worker preferences and expectations, as well as with the broader labour market and economic conditions of the country. Developing greater awareness and competency in managing health workforce labour markets and devising effective policies that harness capacity and resources in both the public and private sector will be an essential feature of an effective strategy to attain any public health goals (43)

(figure 1).

Figure 1. Policy levers to shape health labour markets

Source: Sousa et al. (44).

16. Unless corrective action is taken, the disconnect between the needs of, demand for and supply of health workers will continue in future, contributing to national and global imbalances. In developing health workforce plans that effectively consider, respond to and shape labour market conditions, policy-makers will need to address multiple factors, including (a) estimation of number and category of health workers required to meet public health goals and population needs; (b) capacity to produce sufficient qualified workers

(education policies); and (c) labour market capacity to employ and retain health workers

(economic and fiscal capacity, workforce deployment and remuneration). On current trends, by 2030 low-income countries are expected to face a substantial and widening mismatch between the number of health workers needed to provide essential services (need), the availability of health professionals (supply) and the country capacity to employ them

(demand) (table 1). A modest growth in the capacity to employ workers will lead to a shortage based on economic demand, with the overall supply of health workers remaining constrained. By contrast, upper middle-income countries will see a narrowing gap between the supply of health workers and the numbers needed to provide essential health services.

However, economic growth and demographic trends in these countries will boost the demand for health care beyond the essential services, and the current pace of health worker production will need to be significantly accelerated to meet the demand. This tight labour market condition could potentially raise the cost of health workers, possibly stimulating labour movements across borders and fuelling cost escalation in the health sector in these countries (43). These dynamics, together with a growing demand for health workers in high-income countries, will continue to make international migration of health workers an unavoidable fact. At the same time, high-income countries need to improve their educational investment strategies during times of recession; the countercyclical impact in high-income countries, where health workers seek additional hours or delay retirement during economic downturns, results in newly qualified students being unable to enter the employment market and eventually in them being lost to health care (45).

Table 1. Estimated health worker a deficit b by region and income

Demand-based gap c Needs-based gap (3.45/1000 threshold) d

2012 2030

AEGR

e in supply needed 2012 2030

AEGR in supply needed

Region

East Asia & Pacific 10 505 676 27 329 247 9.26% 1 486 652 2 017 995 1.89%

Europe & Central Asia 1 628 263 4 485 682 2.37% 0 0 NA

Latin America & Caribbean 629 735 2 240 624 6.01% 249 842 427 429 3.12%

Middle East & North Africa 311 899 1 814 130 5.05% 268 459 439 869 3.93%

North America 672 192 3 713 399 3.51% 0 0 NA

South Asia 398 190 3 432 044 3.87% 2 291 638 3 481 713 3.91%

Sub-Saharan Africa 466 113 2 356 154 6.68% 2 103 770 3 757 522 10.21%

Income

Low 187 806 1 118 200 6.36% 2 208 782 3 438 042 11.74%

Lower middle 2 251 233 10 658 754 5.63% 3 091 924 5 013 848 4.20%

Upper middle 9 929 267 24 871 142 8.52% 1 044 690 1 583 102 1.51%

High 2 243 762 8 723 184 2.97% 54 965 89 536 TBC

World 14 612 068 45 371 281 5.64% 6,400,362 10,124,528 3.86%

Notes:

a. Health worker refers to physicians and nurses/midwives (excluding other types of health personnel, such as dentists, pharmacists and administrators). Needs-based estimates are generated from a single model of combined physicians and nurse/midwife data rather than aggregated from separate models for physicians and nurses/midwives.

b. Totals reflect only countries with estimated gaps, defined as the difference between estimated demand or need in

2030 and the current (2012) HRH supply. Surpluses are not counted towards the accumulation of totals. This follows the methodology in The world health report 2006 (15).

c. The demand for health workers is estimated based on a model using per capita gross domestic product (GDP), per capita out-of-pocket health expenditures, and population aged 65+ (see appendix).

d. Campbell et al. (5) utilized ILO’s proposed threshold of 3.45 health professionals per 1000 population. Using a similar methodology, this is the estimated deficit by 2030. The estimate is informed by assumptions in attrition and replenishment of existing staff.

e. AEGR = average annual exponential growth rate required to meet the demand or health worker need by 2030;

calculated for regional/income group gap subtotals.

Source: Scheffler, Liu and Bruckner (46).

3.2 Data and evidence for sound planning and decision-making

17. A dramatic improvement in the availability and use of HRH data for planning and policy-making is both required and possible thanks to technological innovations. A precondition for the understanding of health labour markets and the design of effective policy solutions is the availability of reliable information on health workers’ stock, distribution, flows, demand, supply capacity and remuneration, in both the public and private sector. Data for HRH are available from a variety of sources at national and global levels. However, the use and comparability of data within and across countries is undermined by the diversity of definitions and the lack of norms and standards among

HRH measurement tools (47). Furthermore, there is low capacity to use evidence-based information in HRH planning (48). There is broad consensus on the policy necessity and urgency of improving health workforce data and measurement, and on their application to policy and planning processes. Technological advances, connectedness and the Internet, as well as the rise of new approaches for health workforce futures (49), create opportunities for HRH data collection, gathering and utilization; understanding and using the increasingly available data require focus on tools that enable gathering, storing and utilization of interoperable data and on building analytical capacity. The adoption of information technology-based solutions for HRH data collation and storage, avoiding the capital-heavy infrastructure needed in the past, may represent a leapfrogging opportunity for low- and middle-income countries, although the greatest challenge in these settings lies in the development of the human capital required to operate HRH information systems.

18. The post-2015 agenda requires aligning the public policy agenda on governance, accountability and equity with strategic intelligence on the national and global health labour market. Improvements in HRH information architecture and interoperability can generate core indicators. Data should include a comprehensive overview of the workforce characteristics (public and private practice); remuneration patterns (multiple sources, not only public sector payroll); workers’ competences (including the role of different health workers, disaggregated across cadres and between different levels of care); performance

(systematic data collection on productivity and quality of care); absence and absenteeism and their root causes; and labour dynamics of mobility (rural vs urban, public vs private, international migration) (50). The overall strengthening of HRH data and measurement could in turn lay the foundations for research on cost-effectiveness and return on investment in health workforce interventions (51).

19. Countries should invest in strengthening their analytical capacity of HRH and health system data on the basis of policies and guidelines for standardization and interoperability of HRH data, such as the WHO Minimum Data Set. National and subnational collection and reporting of health workforce data should be encouraged by means of standardized, annual reporting to the WHO Global Health Observatory, and supported also by national and regional HRH observatories. These efforts would be greatly aided by a revision of the current ILO International Standard Classification of Occupations

(ISCO), for greater clarity on classification of health workers and health professions, moving towards competency-based rather than task-based definitions (45). Countries should establish national health workforce accounts that extend the Minimum Data Set to a comprehensive set of key performance indicators on the health workforce labour market.

All workforce data (respecting personal confidentiality) should represent a global public good to be shared in the public domain by governments, health care professional associations and development partners. Incentives should be created for the collection, reporting and analysis of workforce data to inform transparency and accountability, and public access for different levels of decision-making. But a focus on the data will not suffice: capacity-building in both the systems and human capital required to operate them is needed, as well as in how to use data effectively for dialogue with policy-makers. The development of HRH information systems should be professionalized through targeted capacity-building initiatives and the establishment or strengthening of relevant institutions at national level (50).

3.3 Leadership and governance for effective stewardship of HRH development

20. Leadership and governance are enablers of strong health systems. Health workforce development is partly a technical process, requiring expertise in HRH planning, education and management; but it is also a political one, requiring the will and the capacity to coordinate efforts by different sectors and constituencies in society, and different levels of government (52).

Therefore a discourse on effective stewardship and leadership for HRH has both a political and a technical dimension.

21. A key determinant of progress in HRH development efforts is high-level political commitment and accountability mechanisms to guarantee the alignment and coordination of different sectors and constituencies in support of long-term action (53).

Political leadership is needed (a) to establish the national business case for HRH, to support it by necessary regulations, and to use it for demanding plans and budgets from public and private educators and employers of health workers; (b) to marshal support from ministries of finance, education, labour, civil service commissions, local government and the private sector; (c) to accelerate the adoption of innovative processes, technologies, service organization and training delivery modalities; (d) to mobilize adequate resources (whether domestically or internationally in the case of aid-dependent countries) to meet priority health system needs; and (e) to overcome rigidities in public sector rules and practices that hinder the adoption of adequate reward systems and career structures for health workers.

The successful development and implementation of a transformative health workforce agenda requires a “whole of government” approach, with political ownership residing within senior and influential leaders of a country’s parliament and executive branch, and across ministries of labour, finance, health, economic development and education (54).

Without such high-level and sustained political commitment, policies on HRH will not be translated into effective action, and the implementation of global frameworks such as the

WHO Global Code of Practice on the International Recruitment of Health Personnel will remain fragmented. In contexts of frequent rotation of health and other government authorities linked to political cycles, there is always a risk that policy directions are reversed. This risk can be mitigated if stakeholders, including all types of health workers and especially citizens, are engaged in participatory decision-making. This political process must also be able to accommodate the legitimate involvement and interests of a range of stakeholders while not losing sight of public policy objectives. The political economy of health and the influences on decision-making by health professionals and their unions or associations, regulatory bodies, employers’ associations, insurance funders and other stakeholders – sometimes in their self-interest – should also not be underestimated (5). The need to convene multiple stakeholders and resources calls for the establishment of structures and forums for coordinated governance and policy dialogue (55).

22. Committed political leadership needs to be backed by technical and management capacities to translate political will and decisions into effective implementation.

Planners, managers, administrators, service users from the population, academia and professional associations are needed to provide political leaders with quality information for policy formulation, to assess the health and social care workforce implications of any national health goal and target, and to drive the performance of systems for policy implementation in which HRH operate. The public health workforce also needs to connect health workforce development efforts with the wider social determinants of health, including access to housing, food, education and the local environment. Professionals with relevant skills in workforce planning and management should ensure that the approach to workforce development is comprehensive and systemic in terms of occupational groups considered, responsive to needs through an appropriate balance among different cadres and specialty areas (56), and cognizant of the interconnectedness of various dimensions of

HRH policy (education, working environment and conditions, funding and management) and of the private and public sectors. Policies should meet current and future anticipated patient and population health needs and problems. HRH is a constant, evolving dynamic and is best served by continual refinements rather than a static planning process to be revisited only every five years.

23. There is a need to professionalize the field of health workforce planning and management as part of the public health workforce.

Just as we need capable health professionals, we need capable professional health managers. This is essential in order to provide political leaders with the required evidence and technical advice and to guarantee effective implementation and oversight of policies once these are developed (57). At present, health workers, managers who work in health systems and HRH are undervalued, underprepared, undersupported, and underpaid. Reducing the HRH crisis demands better human resources planning and management. Better human resource planning and management demands the availability of an enhanced and strengthened profession.

Professional human resource managers are needed to perform such key duties as advocating HRH development; championing better working conditions, reward systems and career structures for health workers; leading short- and long-term health workforce planning and development; analysing workforce data and labour economics; guiding the design, development and delivery of pre-service and in-service education of health workers;

supporting the development and strengthening of health professional associations;

designing more effective performance management and reward systems; engaging with private sector educational institutions and health providers in a collaborative fashion to support the attainment of public health objectives; and monitoring and evaluating HRH interventions. Capacity in this domain should be nurtured through recognition, incentives and targeted capacity-building initiatives, and we call on WHO to develop an accredited, internationally recognized, postgraduate professional programme on HRH policy and planning, with an international mentoring and professional network to support the implementation of workforce science.

Box 1. Building institutions for HRH development in fragile States and disrupted contexts

In fragile contexts it is critical to prioritize institutional capacity-building. In conflict and postconflict settings and fragile contexts, severe disruption to health systems negatively affects population health outcomes, and health workers may be themselves victims of violence, displacement and conflict. Effective human resource management strategies are critical to addressing the systemic effects of conflict on the health workforce, such as flight of human capital, mismatches between skills and service needs, breakdown of pre-service training, and lack of health workforce data (58).

Responding effectively to the needs of fragile States is an ongoing challenge for the international community, requiring a high level of coordination, setting priorities that meet short- and long-term needs, and promoting resilience in complex systems. Recognizing that State fragility may have different underlying causes, a critical aspect is to understand the type of fragile State and the implications of this on the required interventions: each disrupted context is unique, and solutions have to be developed accordingly. Considering the type or cause of fragility should influence the sequencing of interventions: when a State lacks the capacity to control and implement programmes, systemic sustained development will be difficult to achieve. The technical work demanded to revamp a disrupted health workforce is fairly well understood. In most situations, however, the hardest obstacles lie outside of the health domain, and are of a governance and political nature (59). This is especially true for health workforce development, which requires institutions and policies that ensure a regulatory framework, as well as management and supervision of service delivery. Multiple modalities of intervention for HRH will need to be considered with different starting points, which will be determined by the typology of fragility for each context, by the governance structures

(whether centralized or devolved to peripheral authorities), and by agreeing on entry points which make most impact. Without a strong central system of governance, health workforce interventions may be more effective if targeted at a decentralized level or through non-State actors, where results can be seen more quickly and lessons learned for scaling up. The window of opportunity – when availability of donor funding is often perceived as a chance for stabilization and increasing service coverage – should be seen as a way of making rapid progress towards stronger institutions (60).

Addressing governance issues from a health systems framework is therefore critical, and requires mechanisms for achieving a common understanding of context and interventions that brings all the stakeholders together, with the State in a coordinating role. Finding new ways to measure progress – including a rapid results approach where targets are short to medium term and measured regularly – may be required to accompany the progressive realization of a longer-term vision.

3.4 Mobilizing financial resources and securing their strategic use

24. Public sector intervention to correct for the insufficient provision of health workers, their inequitable deployment or their inadequate performance is needed. In the coming decades the fundamental disconnects between supply and demand in many countries will be exacerbated with greater demands on health services, contributing to persisting migration of health workers towards high-income countries and towards urban areas in countries at all levels of socioeconomic development (5).

Implementing an HRH agenda conducive to the attainment of the health goals in the post-2015 agenda will require greater availability of resources; domestic spending on HRH is lower than is typically assumed (61), and in many low- and middle-income countries greater investments are both necessary and possible. Insufficient investment in the health workforce has often translated into endemic shortages, with management and policy focus diverted to short-term “quick fixes”, contributing to squandering the limited resources available, instead of using them strategically with a long-term focus. The need for funds is extensive for such items as appropriate terms and conditions of employment, better working conditions, incentives for equitable deployment, transformational education and the creation or upgrading of institutions for effective technical stewardship, monitoring and oversight of HRH policy implementation. An essential stewardship function in this context is to mobilize adequate financial resources. The funding levels should reflect the value of effective HRH to the country’s economy by factoring the potential for improved worker productivity in other sectors (62). The HRH financing strategies should extend beyond the traditional 2–3 year planning horizons to 10–15 years. Domestic resources should be mobilized from both traditional and innovative sources, including the general budget, social health insurance, dedicated earmarked funds, ring-fenced excise taxes, and corporate social responsibility funding from extractive industries such as mining and petroleum (54). Leadership and support by ministries of finance will be enablers for effective action to broaden the resource base.

25. But, in addition to securing adequate overall levels of investment, it is perhaps even more critical to ensure the effective use of available resources. A critical challenge lies not just in mobilizing financial resources for the HRH plan, but also in ensuring that these are allocated to the appropriate sections that need to implement it. It has been estimated that globally between 20% and 40% of all health spending is wasted (63), and health workforce inefficiencies are responsible for a large proportion of that. Examples exist of how simple, yet how transformational, cutting wastage on HRH can be, for example by excising ghost workers from the public sector payroll (64). In high-income countries, the challenge will be to balance the growing needs related to an ageing population and new and ever more expensive health technologies with a resource envelope constrained by fiscal retrenchment policies. Economic incentives may naturally lead to the provision of highly specialized and costly care, unless corrective action is taken to align incentives for health workforce education and health care provision to public health goals. Equally critical is to ensure that population demand for specialist care does not lead to underinvestment in general practice and family medicine, a more appropriate and cost-effective approach to provide community-based, person-centred, continuous and integrated care. While the exact make-up of primary care teams should be tailored to meet local needs, the inclusion of a family medicine doctor may be an approach to deliver high-quality and comprehensive primary care (65).

26. In low- and middle-income countries, the foreseen expansion of the health resource envelope should lead to cost-effective resource allocation, and specifically to a workforce geared to a primary health care delivery model. Low- and middle-income countries should take stock of the experience of high-income countries and avoid falling into a trajectory and skills bias toward high-end technology, which may lead them to cost escalation and which may serve the needs of the few who can afford the care (43).

Achieving the health goals of the post-2015 agenda will require a paradigm shift in health care delivery systems, aligning market forces and population expectations towards primary prevention and community and home-based models of care. Such a system requires multidisciplinary primary care teams of health workers with broad-based skills. For example, the nursing scope of practice has been shown to be adaptable to population and patient health needs, and has been particularly successful in delivering services to the most vulnerable and hard-to-reach populations (45). Rather than copying staffing structures and arrangements from abroad, these countries should meld these with lessons from their own rich traditions, especially in programmes involving nurse practitioners, physician assistants and community-based providers (53); There is indeed growing evidence on the effectiveness, accessibility, acceptability (66, 67) and cost-effectiveness (68, 69) of these approaches. In settings where external financial support is still required, the impact of development assistance for HRH development can be maximized if it is more strategically targeted (see also section 4) (70).

27. These HRH reforms should take place in the context of substantial changes in the health care delivery model that will lead to improvements in health workforce productivity. Opportunities for innovation exist, including through the use – where relevant – of performance-based incentives (71), and of technological innovations that save costs rather than increase costs, contributing to the attainment of health goals in an affordable and fiscally sustainable manner. Policy and regulatory responses will be needed to improve utilization and efficiencies in health care, and enable optimization of services, for example by up-skilling current workers and allowing greater flexibility in determining the appropriate skills mix (43), while overreliance on task delegation should be avoided.