New plan to tackle the global shortage of health workers fails to address economic constraints

msflogoThe Five-Year Action Plan for Health Employment and Inclusive Economic Growth from the World Health Organization, International Labour Organization, and the Organisation for Economic Co-operation and Development was recently adopted. It was developed from the Global Strategy on Human Resources for Health: Workforce 2030. [1,2] Together, the global strategy and the action plan address issues around the uneven distribution of health workers and severe shortages globally. While the action plan highlights the positive economic benefits of investing in human resources for health (HRH), it largely fails to address the economic constraints to implementing it. [3]

The strategy forecasts the creation of 40 million additional jobs to meet the global “demand” by 2030—but mainly in high and middle income countries. Demand is based on the country’s domestic capacity to fund such jobs and implies only 0.5 million of these extra jobs will be generated in Africa, to meet their total demand of 2.4 million workers. However, calculations based on SDG norms (4.45 professional health workers/1000 inhabitants) indicate that 7.6 million health workers will be needed in Africa in 2030. Benchmarks based on an ability to pay maintain fundamental inequities in target setting and hide the widening mismatch between HRH needs and availability.

Several of the action plan’s recommendations refer to increasing health workers through increased investment in training and “life long learning.” While laudable, it is not enough. Although the shortage of health workers can in part be addressed through increased and improved supply, experience suggests that significant numbers of existing trained workers cannot enter the public health sector due to limited finances and fiscal space to absorb and remunerate them adequately in the public payroll. [4]

A large part of the health workforce in many poor countries is not on the official payroll. In Sierra Leone, 9350 health workers—approximately half of the professional health workforce—are unpaid volunteers, often waiting years to be recruited in the public sector. A similar situation exists in Guinea and in Mozambique, where over the past eight years thousands of health professionals waited to be included in the Ministry of Health payroll. [5,6] The renewed interest in task-shifting to community health workers overlooks the need to go beyond unpaid volunteers and improve their supervision, support, and career development; they too face inadequate remuneration and poor working conditions. [7]

The systematic underfunding of health workers in the public health system also leads to downstream financial barriers to patient access through staff’s dependence on patient fees. [8] The health system in Guinea largely relies on patients’ out-of-pocket payments to complement low state salaries or payment to “volunteers.” In Sierra Leone patient payments demanded by these volunteers undermine the application of the Free Health Care Initiative. [9] Furthermore, because patients are more likely to be able to pay in larger cities, this reinforces the uneven urban-rural distribution of health staff.

While the action plan highlights important problems, it fails to address critical points related to who will finance the recommended plans. The global strategy asserts that domestic resources for HRH “should be supported by appropriate macroeconomic policies at national and global levels” and that at least in certain circumstances “countries will require overseas development assistance for a few more decades to ensure adequate fiscal space” (part 38). Still, the action plan and the global strategy specify neither the criteria to assess such needs for continued international support, nor do they recommend measures to lift fiscal space limitations.

As international aid for health continues to flat-line or decrease, the current international aid discourse expects expanding health services to rely mainly on increases of domestic funding, even in resource limited settings. However, such reliance on domestic funding remains unrealistic in most countries and will stall progress towards the SDGs. In Lesotho, where international donors previously supported approximately 500 (lay) counsellors, in 2012 over half stopped working due to a reduction of funding and a lack of government capacity to absorb this funding cut. It negatively impacted on HIV testing programmes. [10] Similarly, HIV testing rates in Kwazulu Natal, South Africa, dropped by at least 25% when the government phased out the lay counsellor cadre in 2015. [11]

Countries struggling to address health challenges need sustained international support and targeted measures to address underlying inequities in the global health workforce distribution.

How do we ensure the effort to create HRH jobs and economic opportunities includes public health benefits for people affected by ill health in low resource contexts? While welcoming the global momentum towards investing in the health workforce, we fail to see how the action plan as it stands could drive the intended changes in public health. The improvement and expansion of training cannot translate into expansion of public services for those who need it most unless we ensure that health workers are absorbed into the public sector. If not, such workers may simply expand the private sector or boost the international brain drain.

To achieve increased access to free, quality services that advance the health status of everyone, including those most in need, WHO and other global health actors need to address the elephant in the room. Otherwise health workforce ambitions risk being trampled.

Marielle Bemelmans is a public health professional (PhD) with over 15 years of experience in global health, mostly working for MSF with a focus on human resources for health, health policy analysis, and advocacy. Since April 2017, Marielle has been the director of Wemos Foundation, the Netherlands.

Mit Philips is a medical doctor with an MPH, who worked abroad for 15 years for Médecins Sans Frontières. Since 2000 she’s been based at MSF’s headquarters in Brussels as a health policy adviser in the analysis department, with a focus on global health policies and health in fragile states. She was also part of the team of Health Policy and Planning, the Institute of Tropical Medicine in Antwerp, Belgium (2010-2012).

Competing interests: None declared.

[1] OECD, ILO and WHO (2017) Five-Year Action Plan of the High-Level Commission on Health Employment and Economic Growth. Geneva.

[2] WHO (2016). Global Strategy on Human Resources for Health: Workforce 2030. World Health Organisation: Geneva.

[3] Shapovalova N, Meguid T, Campbell J. Health-care workers as agents of sustainable development. The Lancet 2015;3:5.

[4] Kentikelenis A, King L, McKee M, Stuckler D. The International Monetary Fund and the Ebola outbreak. Lancet Glob Health. 2015:3:e69-70.

[5] Van de Pas, R. and Van Belle, S., 2015. Ebola, the epidemic that should never have happened. Global Affairs, 1(1): 95-100.VSO. 2015.

[6] Philips M., Dying of the Mundane in the Time of Ebola:  The effect of the epidemic on health and disease in West Africa. Chapter 5 in The Politics of Fear. Médecins Sans Frontières and the West African Ebola Epidemic. Oxford University Press 2017.

[7] Tulenko K, Mogedal S, Afzal M, Frymus D, Oshin A, Pate M, Quain E, Pinel A, Wynd S, Zodpey S. Community health workers for universal health-care coverage: from fragmentation to synergy. Bull World Health Organ. 2013 Nov 1;91(11):847-52.

[8] Ponsar F, Tayler-Smith K, Philips M, Gerard S, Van Herp M, Reid T, Zachariah R. No cash, no care: how user fees endanger health—lessons learnt regarding financial barriers to healthcare services in Burundi, Sierra Leone, Democratic Republic of Congo, Chad, Haiti and Mali. International Health 2011:3(2):91.

[9] Witter, S; Wurie, H; Bertone, MP (2015) The free health care initiative: how has it affected health workers in Sierra Leone? Health policy and planning. ISSN 0268-1080 DOI: 10.1093/heapol/czv006. Downloaded from: http://researchonline.lshtm.ac.uk/2137768.

[10] Bemelmans M, Goux D, Baert S, van Cutsem G, Motsamai M, Philips M, van Damme W, Mwale H, Biot M, van den Akker T. The uncertain future of lay counsellors: continuation of HIV services in Lesotho under pressure. Health Policy and Planning 2015, 1-8.

[11] Presentation MSF Eshowe project, IAS Durban 2016

[12] DFID (2010). Evaluation of the Malawi’s Emergency Human Resources Programme. Cambridge, USA: Management Sciences for Health. http://www.who.int/workforcealliance/media/news/2010/Malawi_MSH_MSC_EHRP_Final.pdf

[13] MSF (2016). HRH Assessment Malawi – internal report. Brussels, Belgium: Analysis and Advocacy Unit, Medecins Sans Frontieres.

  • joe

    Dear Ms. Bemelmans,

    I hope your day is going well, my name is Joe Zarif, and I also want to express the economic and social restraints behind this doctor shortage. The main issue at hand is the shortage of medical care workers in countries that do not have the financial support as you stated such as Guinea and Mozambique. This idea of an action plan is absolutely necessary and I believe one should be fulfilled as soon as possible. As I understood from your article, the main point of concern is, who will pay for the workers that are in those countries since most are mere volunteers. This is definitely a top priority, But I also believe that there are obstacles occurring prior to that stage that hinder the efficiency of this plan.

    I would like to address the cost of school to become a part of the medical work force. Medical school tuitions and cost are the ones preventing potential students from even pursuing their dream of becoming doctors, because working in Africa, or southeast Asia in countries where extensive work is not promised, thus the repayment of the student loans is not guaranteed. Doctors work best when they are located on a country that communicates in their own language, and unfortunately most countries in Africa do not even have medical programs that can allow doctors to practice in the language they have been raised with. This problem adds an even higher cost for a potential student to travel to America or another county to study the art of medicine. While the practice of treatment is a long and demanding workload, something must be done about allowing students that plan on working in those environments to have their schooling paid for. My solution to this idea is tied into the next point I am going to make as well.

    The United States foreign aid spending budget accounts for about one percent of our total government spending. That is not composed of solely medical needs, but everything that has to do with foreign aid. This is the main source of the shortage. Unfortunately, our president also introduced the idea that we are spending too much on foreign aid and would like to cut overseas spending. We can afford to spend a significantly larger amount of money and aim that to the training of local doctors to, developing clinics, as well as aiding already established non-profit organizations to expand and pay their volunteers. The money to pay for these doctors, that you state in your article has to come from the developed governments of the first world. Another solution I have for this action plan is to require doctors of different specialties that are already established in developed countries to aid the people in need. An incentive will be offered to the doctors, and the quality of help will increase with where they are working teaching local doctors techniques that can help them in the future. We cannot just focus on creating 40 million jobs for the sole purpose of numbers, we also have to think about the quality of aid that is at hand. If the quality is not up to standards that you would want to be treated with. I believe that the main focus should be giving the locals the opportunity to access the education needed to help aid people in their own needed environments to start momentum. Private sectors should not even be thought of to provide clinics and other organizations with funds, because our government is more than capable of funding this process.

    I would love to hear your response as a public health official on where we stand in regards to preliminary educational issues that could stem this shortage. Thank you very much for your insight, I hope to explore this topic further.

    Sincerely,
    Joe Zarif