The Ebola epidemic in the Western African Region has reminded the international community why it is so important to have a skilled health workforce in place to provide essential and universal health services. It is a crucial requirement to contain outbreaks of re-emerging infectious diseases. Sadly, it is this very scarce workforce that has been hit hardest by the Ebola epidemic. As of 11 February 2015, after a decline in recent weeks, the epidemic showed again a sharp increase of cases in Guinea. It ain’t over till it’s over, unfortunately. Till now, 830 health workers got infected, of which 488 have passed away.
More in general, the global health workforce requires serious attention. Due to demographic growth in different regions in the world, an ageing workforce and an epidemiological transition to chronic disease worldwide, there is a desperate need for more skilled health workers, to contribute to a balanced workforce tailored to countries’ needs. In 2013, approximately 7.2 million more midwives, nurses and physicians were “missing and thus not in action” – and this shortfall is predicted to rise further to at least 12.9 million in the coming decade. The gap is most obvious in low- and middle countries (LMICs), but has become an issue in other regions as well, including in the North. See for instance Europe, where many health workers have decided to migrate to countries in Northern Europe for employment reasons. This has created inequalities in access to health services. In sum, the global health workforce crisis is (or should be) a major issue for the post-2015 development agenda. The public health community has been convinced of this for a long time, now hopefully also Obama, Cameron and other Xi’s are on board.
In 2015 four important global policy discussions take place that will shape the direction of the health workforce development for the coming decade. First, the relevance and effectiveness of the Code of Practice on the international recruitment of health personnel (WHO Code) will be discussed at the 68th World Health Assembly in May 2015. Secondly, WHO and the Global Health Workforce Alliance are developing a global strategy on Human resources for health. Thirdly, the future institutional development of the Global Health Workforce Alliance (GHWA), the Global health initiative created in 2006 to raise the global profile and funding of the health workforce, is hotly being debated. Finally, the position of the health workforce within a future 3rd (Health) Sustainable Development Goal is to be defined.
During the first round of reporting on the Code in 2013, the WHO Secretariat informed the Assembly that only 84 designated national reporting authorities had been established and that it had received even less (51) reports. A WHO Assistant Director-Ggeneral admitted during a side-event at the WHA that year that progress was ‘painfully’ slow. We will have to see how Member States will contribute to the second round of national reporting due this year.
Unethical recruitment and inadequate investment in self-sufficiency in high-income countries are crucial contributors to global health workforce imbalances, underlying the continuing relevance of the WHO Code. The WHO Code needs to be properly implemented, including in Europe, and national health workforces need to be developed, nurtured and retained. Having said that, one should not shy away from also asking the (obvious?) question whether the voluntary nature of the Code detracts from its effectiveness, and WHO should thus move to the negotiation of a more binding instrument to address recruitment and migration issues in the context of a broader HRH strategy. In a joint statement during the Executive Board meeting of WHO, we recommended Member States to consider rescheduling the commitment to report on the relevance and effectiveness of the Code to the World Health Assembly in 2016. This would allow some more time for a proper process, including full consideration of the information gathered through this second round of national reporting. It also would align more closely the processes of Code review and the development of a global HRH strategy planned for this year.
In 2013, the Board of the Global Health Workforce Alliance facilitated the development of strategic thinking on human resources for health. 8 Thematic working groups wrote a thematic paper as input for a global strategy; a synthesis report summarizes the papers of these 8 thematic working groups. The Medicus Mundi International (MMI) network, together with several others, has been following this process closely, providing feedback for further dialogue. Our main critique is that the global strategy mainly mentions national responsibilities and requirements (multisectoral approaches and labour market analyses) to develop the workforce, but fails to recognise the transnational dimension, international legal frameworks and human rights aspects of health workforce governance. The international moral responsibility and ethical imperative that everybody should have access to skilled health workers providing essential health services is lacking from this strategy. The synthesis paper takes a rather narrow approach: it makes the ‘instrumental’ economic and health security case for investments in the health workforce, but doesn’t recognise the intrinsic value of developing public services for health, the social role of health workers nor the role they can play as change agents in society.
GHWA’s mandate ends in 2016. There is now a debate on how to move forward with a GHWA 2.0. GHWA is currently hosted by (and working in close cooperation with) WHO. Alternative options would be for GHWA to work in close cooperation with other institutions such as the World Bank or the International Labour Organisation, or that it becomes a more autonomous, independent organisation. We think there are already too many global health initiatives, and too much fragmentation and bilateral control within the existing agencies and policies. GHWA should remain closely affiliated with the WHO, so that the latter’s social justice & equity values and health objectives also remain key priorities for GHWA. These aspects could be neglected in case of an “ever closer union with” the World Bank, as the Bank mainly focuses on poverty alleviation and harnessing economic growth.
The proposed Health sustainable Development Goal (3) has four suggested modes of implementation. One of them is 3c: “Increase substantially health financing and the recruitment, development and training and retention of the health workforce in developing countries, especially in LDCs and SIDS”. The SDG agenda will be negotiated and decided upon in the coming months (if God and Mr Putin allow so). There is already much discussion on what a truly ‘universal’ framework implies within international cooperation, and whether blatant inequalities (as is the case with the workforce) will be redressed. A crucial element will be what comes out of the financing for development summit, later this year in Addis Abeba, Ethiopia. If all goes well, an agreement there should provide the financial means (national and global taxation?) for investment in the workforce in countries that lack an essential level of health workers.
The GHWA board will come together on 25/26 February 2015 to discuss the further process and policy direction for at least 3 of the 4 issues above (except the SDG framework, for which the main action takes place in New York). WHO will discuss both policy and process during the upcoming World Health Assembly in 2015. It is important to follow these policy debates closely, and to engage with them as much as possible, via a critical but constructive dialogue with all actors involved. A good way to kick off this dialogue is via Twitter. One could approach GHWA and its director Jim Campbell via @GHWAlliance resp @Integrare. The hashtag #GHWAboard18 could be used to take part in the policy debate during the board meeting itself, from a distance. Many of the GHWA board members use Twitter as well and could perhaps be contacted. The notes of the 17th board meeting are also accessible.
Many steps still need to be taken this year to take the various (abovementioned) processes forward. The important thing, as always, is that we walk in the right direction…