In 2015, the United Nations issued the Agenda for Sustainable Development Goals,(1)
which highlighted the need to ensure healthy lives and promote well-being for all
across the lifespan. Goal 3 aims to make sure everyone has access to health and health
coverage and, in 2019, the United Nations General Assembly adopted the political declaration
of the high-level meeting on universal health coverage reaffirming that “health is
a precondition for and an outcome and indicator of the social, economic and environmental
dimensions of sustainable development”.(2) The High-Level Commission on Health Employment
and Economic Growth identified that investments in the health and social workforce
can spur inclusive economic growth.(3)
Achieving Goal 3 requires health services that are accessible (available and affordable),
culturally acceptable and that provide quality care by well-trained health workers.
The World Health Organization (WHO), however, estimates a worldwide projected shortfall
of 18 million health workers by 2030, mostly in low- and lower-middle income countries.
Countries at all levels of socioeconomic development face –to varying degrees– difficulties
in employment, deployment, retention, and performance of their workforce due to chronic
under-investment in education and training of health workers and the mismatch between
education and employment strategies in relation to health systems and population needs.(4)
The Pan American Health Organization/World Health Organization (PAHO/WHO) has a long
history of contribution to the development of human resources for health in the Region
of the Americas through pioneering actions such as calling for regional action to
implement policies for the development of human resources in health in areas such
as regulation, education, professional practice, work, and specialized migration,
as well as the creation of observatories and the Virtual Campus for Public Health.
Its “Strategy on Human Resources for Universal Access to Health and Universal Health
Coverage” (5) offers guidance to countries to progress towards improving the availability,
accessibility and quality of their health workforce. Evidence-informed workforce policies
are of critical importance in support of strong and resilient health care systems.
In alignment with the priorities set by the Strategy, a special issue of the Pan American
Journal of Public Health on “Human resources for Universal Health” was planned at
the end of 2019 as a contribution to implementing the vision of the Astana Declaration
on primary health care (6), with the goal of stimulating research on three topics:
governance, capacity building, and education and training of health workers.
Research can produce actionable evidence for governance on how decision-making, planning,
regulation, inter-sectoral and inter-organizational coordination, leadership and management
mechanisms are conducive to the design and implementation of workforce policies that
respond to the rapidly changing needs of the populations in equitable manner. There
is equity in access when all members of a population have the same level and quality
of access to health workers, according to need, irrespective of their capacity to
pay and without any form of discrimination (social status, ethnic origins, religion,
sexual orientation, etc.). Access to health workers is equitable when it is modulated
in function of the importance of the need, e.g. urgency, or the severity of the health
problem, and when health workers provide the same quality of service to all people
who need it.
As regards to capacity building, it is critical to establish the technical and leadership
skills that are available at all levels of the policy development and management of
the workforce, and to create and sustain supportive management that motivates and
enables workers to provide services at the highest level of quality.
We also need more clarity about how to align education
and training programs with the needs of health services, so that they equip health
workers from their initial training and all along their professional life with relevant
competencies.
Then came the COVID-19 pandemic! In a matter of weeks, even days, it did more than
all past advocacy efforts to highlight in real time the critical role of health workers,
vital to respond to emergencies and disasters. All of a sudden, physicians, nurses,
auxiliaries, ambulance staff, and all support personnel became heroes. However, it
soon became clear that the commitment demonstrated by health workers was not enough
to respond adequately to the crisis. Numerous deficiencies in the management of the
health workforce became visible to all, from users of services to political decision-makers.
In addition to insufficient numbers of workers overall, the crisis revealed inequities
of access due to shortages in certain regions, typically rural, remote and poor. In
many countries of the Region, this is compounded by the underutilization of the skills
of diverse occupational groups, like nurses and pharmacists, and by an inefficient
composition of the workforce, with low ratios of nurses (7) and other personnel to
physicians, and of generalists to specialists. It also threw light on the often difficult
working conditions of health staff, their low remuneration, and the gaps between what
is necessary to provide a good response to the needs of the sick and what is at their
disposal. It showed the need for upskilling personnel working in intensive care units,
in homes for the aged and the disabled, and physicians and nurses needed training
in the use of telemedicine.
Even if this was not news to students of health labor markets, it was a wake-up call
for policy-makers and the public. The recognition of these problems is a prerequisite
to the introduction of change. So what needs to be done given that COVID-19 has made
this problem so obvious? This is where research finds its purpose and applicability
and where sound scientific evidence can make a contribution to informing policy-making.
The workforce situation needs to be well documented, the causes of its weaknesses
understood, and above all, the options to intervene, what works, what does not work,
all need to be identified.
Some important questions remain: Will the crisis be a catalyst of policy change? Will
governments spend more on health services and their workers? Spending on the health
workforce, if done well, is a good investment. The challenge is for countries to develop
policies that generate efficiency and effectiveness; planning a more rational balance
between community health workers, nurses and physicians; expanding the scope of practice
to make the full potential of each cadre available; systematic regulation of education
and of practice; and the creation of enabling work environments. The result will not
only be better health indicators, but also economic growth.(8) It could also avoid
or help mitigate the disastrous economic consequences that the world has experienced
as a result of the 2020 public health crisis.
The publication by the Pan American Journal of Public Health of this special issue
on human resources for universal health seems timely as it coincides with the International
Year of the Nurse and the Midwife and with the landmark publication of the State of
the World’s Nursing 2020 Report.(9) This issue presents research on the most important
resource of health services –its workers. We hope the articles provide valuable experience
and evidence that will inform decisions and health policies in the Region going forward
and provide impetus to the implementation of the Declaration of Astana.