By World Healthcare Journal-
As crisis looms in the healthcare workforce, with an estimated 18m workers required by 2030, WHJ Publishing Director Steve Gardner discusses the World Health Organization’s role in ensuring a sustainable health workforce with WHO Director of Workforce, Jim Campbell.
How would you describe WHO as an entity?
WHO works worldwide to promote health, keep the world safe, and serve the vulnerable. This week we embark on the 72nd world health assembly. The Assembly is the decision-making body for WHO. It meets in Geneva and is attended by delegates from all 194 Member States. Its main function is to determine the policies of the Organization.
Over the next 10 days there are many health topics for discussion, including Universal Health Coverage and how we operationalise primary healthcare. From a health workforce perspective, we have several items of discussion. There are agenda items on the Global Strategy on HRH: Workforce 2030, the role of community health workers in primary healthcare, and WHO’s Global Code of Practice on the International Recruitment of Health Personnel. There is also a decision on designating 2020 the year of the nurse and the midwife.
As an organisation, how do you ensure that the Assembly’s discussions are operationalised?
In many of the decisions of the assembly member states agree monitoring and accountability frameworks to measure progress. Progress maybe against improvements in health outcomes or changes over time, for instance on financing and investments in health. This change takes place in the health policies, systems and healthcare facilities in the countries. And that change and accountability sits with each jurisdiction, turning evidence into practice. Decisions in the Assembly can stimulate and promote consensus, and lead to change and accountability at the local level. We hear a lot about crises, issues, problems that we've got in terms of workforce - how real are those issues? And what are the consequences if we don't do something about them?
One of the most enjoyable roles in the WHO's bringing experts and evidence together, and to look at some of the global macroeconomic and drivers of change that we can anticipate within healthcare. Globally, we’re seeing some red flags popping up. For instance, there’s a mismatch between the need for health workers, the supply of health workers from education institutions and the economic demand within healthcare systems to create jobs. The mismatch globally does raise questions about the intersectoral nature of education and employment in the health sector. Is the education sector talking to the health sector, and are they both talking to the employment sector? Is government joined up on these issues?
Similarly, by looking at data across countries we see increasing migration and mobility of health personnel . Across the world there is undoubtedly variation but we see a pattern, an unweighted average, that nearly 1 in every 4 jobs in a health system may be held by somebody who was born or educated in a different country. This is particularly the case across the major regulated professions in healthcare, for example -nurses, doctors, pharmacists. We shouldn’t be surprised. Migration is a fundamental practice of the human race. And the migration of people who are highly skilled and have a set of competencies that are in demand is increasing across many different professions, not only the health professions.
Is there a concern that migration is a red flag, taking valuable healthcare resources and workers away from developing healthcare economies?
There is a concern, which has been discussed in the Assembly over many years, about the global mismatch between the supply/need/demand of health professions. This mismatch is a factor in migration. And yes, migration can result in the loss of valuable capacity. At the same time, there is also evidence that migration can be a positive thing. There needs to be a balance. There is consensus of the member states that migration of health personnel has to be ethical with mutual benefits for the source country, the destination country, and the individual health worker
For instance, how to ensure that if health workers to migrate that their labour rights are protected, e.g. that they receive equal pay for equal work and have the same terms and conditions. We also have to recognise that patterns of migration are complex. In many instances a country will be both a source and destination country. Health workers leave and others will enter. There are many myths about migration that the data challenges.
How do you actually police that sustainable relationship?
WHO doesn’t police, but there are mechanisms and frameworks that support accountability. In 2010, member states agreed a global code of practice on the international recruitment of health personnel. The Code took six years to negotiate and agree. In that instrument, there is an accountability framework. We will have a discussion on this at the world health assembly this week. This year, more than 80 member states from around the world have submitted voluntary reports back to the World Health Assembly, contributing their data about how they are implementing the Code and how many foreign-born and/or foreign-trained health workers are within their health systems.
So, I wouldn’t say policing, but there is a consensus process of monitoring progress and there is a mechanism of regularly reviewing the Code and if it needs to be brought up to date based on new evidence.
What we can we do about the shortage of health workers?
The evidence tells us that there is an unmet need for more health workers in many countries. As nations invest more in the health of their populations, more jobs are created. We need to get the supply to match and look at the role, the tasks and the skills for the future workforce with the ambition of universal health coverage, we need to expand the capacity of the system to be able to reach people.
This is where we see the 18m shortfall - we need to invest in education, training, employment because otherwise we won’t have the workforce to provide access to healthcare and reduce the burden of disease.
How do you manage to maintain the quality and standards required in order to meet people's healthcare needs?
Governments have a role to protect the public. They do so through regulatory frameworks, accreditation of education institutions, health professional education, licensing, to ensure that quality standards for health workers within a jurisdiction are actively promoted. The same is true for medicines, vaccines and medical devices.
However, the world is changing. There is the internet. There may be quality-control within a country, but the internet allows consumers to purchase medicines outside of national boundaries. And there are many websites and applications, accessible through mobile phones, where people may be tempted to self-diagnose. There’s a governance issue here to protect the public from misinformation, especially if this leads to instances such as the measles outbreak around the world right now.
What is the role of the WHO in terms of ensuring we hit the relevant standards? Are there moves towards creating global standards?
There is a lot of evidence that regulatory frameworks can have a significant impact on protecting the public. There are good standards, and there are accountability mechanisms, checks and balances on how to keep them. However, there is a great deal of work to be done in lifelong learning. We do want to look at the WHO’s role in improving lifelong learning and how we can bring that into the 21st century.
So how do we resolve the workforce crisis?
The workforce challenge is global, but yes it is most acute in some of the low and middle income countries. There are about 30 countries where the current supply and economic demand for health workers may not be sufficient to meet the ambition of universal health coverage. Creating jobs is stifled, in part, by domestic revenues and the recurrent expenditures for wages. So we really have to think about how, in those environments, we might generate other forms of financing, including international investments. We demonstrated with the evidence from the UN’s high-level commission on health employment and economic growth that we need to stimulate education and job creation in those economies if we want to accelerate progress on universal health coverage.
Is there a way, then, in which we can reduce the number of health workers needed by using technology?
Technology has a huge potential to increase productivity in healthcare and how we use it could have an impact in terms of how we distribute workforce resources. But in some countries, technology won’t replace the absence of people, so we've got to build the capacity of the workforce and deploy technology to have those additional benefits.
We also see countries achieving better health outcomes as a result of the distribution of the workforce, the skills and incentives in the system. So you’re right it’s not just a numbers issue. Every country has to look at their current health outcomes, their health priorities, their health system - and ask the single question - what are the workforce implications?
Jim Campbell is the Director of the Health Workforce Department at the World Health Organization. His role at WHO has included overseeing the development of WHO’s Global Strategy on Human Resources for Health: Workforce 2030 as adopted by the 69th World Health Assembly.
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