Human resources for universal health coverage: a call for papers.

The Third Global Forum: framing the health workforce agenda for universal health coverage.

Francis Omaswa: tackling the shortage of health workers

Kenya is committed to achieving Universal Health Coverage (UHC) within its devolved health system in which significant investments have been made in health infrastructure, workforce development, and service delivery. Despite these efforts, the country faces considerable health workforce challenges. To address these, the Ministry of Health undertook a comprehensive Health Labour Market Analysis (HLMA) in 2022 to generate evidence supporting the development of responsive health workforce policies. This paper presents findings of a modelling exercise to understand the health labour market outlook. As part of a comprehensive HLMA, a validated needs-based health workforce modelling framework was applied to project the supply, needs, and investment requirements. Data was triangulated from multiple sources through desk reviews and group modelling by an expert technical working group constituted to undertake the study. The analysis considered disease burden, population growth, service delivery models, and health worker productivity, to assess the future health workforce needed. Kenya’s health workforce is growing, with approximately 7,650 new workers added annually, resulting in an estimated 3.4% annual growth. By 2025, the health workforce is projected to reach 226,434, increasing to 263,700 by 2030. However, Kenya required a minimum of 254,220 health workers in 2021 to make substantial progress toward UHC. The cumulative need could rise to 476,278 by 2035. In 2021, Kenya had a needs-based shortage of nearly 60,000 health professionals, which could increase to 114,352 by 2030. The financial space for health workforce was estimated at US$2.29 billion in 2021 and is projected to rise to US$3.58 billion by 2030, but the required wage bill potentially reaching US$3.9 billion. Kenya must significantly increase investments in its health workforce to meet UHC goals. Both public and private sectors need to contribute more, with the public sector requiring a health workforce budget increase of 10.5% annually to bridge the projected funding gap.

David Evans: putting universal health coverage on the agenda

BackgroundAngola is among sub-Saharan African countries dealing with a crisis of Human Resources for Health (HRH). The province of Cabinda, besides the efforts, still suffers from both HRH shortage and a badly distributed health workforce. In Cabinda, one can find urban concentration and rural shortages of healthcare professionals, many rural areas’ healthcare facilities often secured only by basic or medium level HRH; and difficulties in developing HRH retention strategies in rural areas where most services are covered by foreign HRH. This study aims at analysing the situation of HRH in the province of Cabinda. It considers organizational issues, policies and practices resulting from the HRH strategy followed in the recent years, moreover the creation of a medical school. The context that affects the distribution of the health workforce is analysed to contribute to the development of evidence-based policies that promote a better HRH allocation in the poorest and distant villages in the province.MethodsA mixed-methods study was developed, combining a quantitative and qualitative approach to analyse HRH situation in the province of Cabinda. Data was collected from key informants, selected by intentional sampling from public and private health organizations, to respond to a questionnaire and a semi-structured interview. Quantitative and qualitative data was analysed with descriptive and inferential statistics and content analysis respectively. The study was complemented by a comprehensive desk review.ResultsResults show a clear change in HRH data from 2011 to 2015 with significant fluctuations due to variations in retirement, migration and lack of regular public HRH recruitment tenders. HRH density is apparently better in rural when compared with urban areas. However, one should bear in mind that often HRH allocated to rural areas do not stay there, which leads to real geographical imbalances. Factors like lack of proper incentives for HRH retention and social support goes against significant HRH management efforts contributing to this result. Whereas HRH are financed by the State General Budget, the majority of health facilities are still dependent on the Provincial Health Secretariat budget.ConclusionThe study provides a broader view of the current HRH situation in Cabinda Province. Geographical imbalances and other issues with impact in delivering universal access to healthcare are highlighted.

BackgroundGlobal Health Initiatives (GHIs), aiming at reducing the impact of specific diseases such as Human Immunodeficiency Virus (HIV), have flourished since 2000. Amongst these, PEPFAR and GFATM have provided a substantial amount of funding to countries affected by HIV, predominantly for delivery of antiretroviral therapy (ARV) and prevention strategies. Since the need for additional human resources for health (HRH) was not initially considered by GHIs, countries, to allow ARV scale-up, implemented short-term HRH strategies, adapted to GHI-funding conditionality. Such strategies differed from one country to another and slowly evolved to long-term HRH policies. The processes and content of HRH policy shifts in 5 countries in Sub-Saharan Africa were examined.MethodsA multi-country study was conducted from 2007 to 2011 in 5 countries (Angola, Burundi, Lesotho, Mozambique and South Africa), to assess the impact of GHIs on the health system, using a mixed methods design. This paper focuses on the impact of GFATM and PEPFAR on HRH policies. Qualitative data consisted of semi-structured interviews undertaken at national and sub-national levels and analysis of secondary data from national reports. Data were analysed in order to extract countries’ responses to HRH challenges posed by implementation of HIV-related activities. Common themes across the 5 countries were selected and compared in light of each country context.ResultsIn all countries successful ARV roll-out was observed, despite HRH shortages. This was a result of mostly short-term emergency response by GHI-funded Non-Governmental Organizations (NGOs) and to a lesser extent by governments, consisting of using and increasing available HRH for HIV tasks. As challenges and limits of short-term HRH strategies were revealed and HIV became a chronic disease, the 5 countries slowly implemented mid to long-term HRH strategies, such as formalisation of pilot initiatives, increase in HRH production and mitigation of internal migration of HRH, sometimes in collaboration with GHIs.ConclusionSustainable HRH strengthening is a complex process, depending mostly on HRH production and retention factors, these factors being country-specific. GHIs could assist in these strategies, provided that they are flexible enough to incorporate country-specific needs in terms of funding, that they coordinate at global-level and minimise conditionality for countries.

The Global Health Workforce Alliance was launched in 2006 to provide a joint platform for governments, development partners, international agencies, civil society organizations, academia, private sector, professional associations, and other stakeholders to work together to address a global crisis in human resources for health. Five years later the vision and mandate of the Alliance still remain valid. Despite advances in bringing the health workforce to the fore in international health policy arenas, more available knowledge and tools, and encouraging signs of commitments from many countries, health workforce bottlenecks continue to prevent many health systems from delivering essential and quality health services. Latin America is not spared from the challenges. The 2010 Second Global Forum on Human Resources for Health provided an opportunity to review progress, identify persisting gaps, reach consensus on solutions, and renew the momentum for and commitment to acutely needed investment and actions.

ObjectivesIndonesia aims to achieve universal health coverage (UHC) and Sustainable Development Goals (SDGs), including SDG 3 target 4, which focuses on cancer control, by 2030. This study aimed to forecast...

The crisis in human resources for health

2009: a crucial year for progress on the health workforce crisis

Human resources for health (HRH) in the Sudan were limited by shortages and the maldistribution of health workers, poor management, service fragmentation, poor retention of health workers in rural areas, and a weak health information system. A "country coordination and facilitation" process was implemented to strengthen the national HRH observatory, provide a coordination platform for key stakeholders, catalyse policy support and HRH planning, harmonize the mobilization of resources, strengthen HRH managerial structures, establish new training institutions and scale up the training of community health workers. The national government of the Sudan sanctioned state-level governance of the health system but many states lacked coherent HRH plans and policies. A paucity of training institutions constrained HRH production and the adequate and equitable deployment of health workers in rural areas. The country coordination and facilitation process prompted the establishment of a robust HRH information system and the development of the technical capacities and tools necessary for data analysis and evidence-based participatory decision-making and action. The success of the country coordination and facilitation process was substantiated by the stakeholders' coordinated support, which was built on solid evidence of the challenges in HRH and shared accountability in the planning and implementation of responses to those challenges. The support led to political commitment and the mobilization of resources for HRH. The leadership that was promoted and the educational institutions that were opened should facilitate the training, deployment and retention of the health workers needed to achieve universal health coverage.

In 2008, the Global Health Workforce Alliance commissioned a technical working group to examine the human resources for health implications of scaling up to reach the Millennium Development Goal 6 of universal access to HIV/AIDS prevention, treatment, care, and support by 2010. The analysis and interventions recommended in the working group report, which was launched at the Second Global Forum on Human Resources for Health in Bangkok, Thailand, in January 2011, are based on two research methods: literature reviews covering the period from 2000 to 2008 and a rapid situational analysis produced by teams working in 5 countries (Côte d'Ivoire, Ethiopia, Mozambique, Thailand, and Zambia). The authors' intent in this article is to assist the Alliance in maintaining the momentum of the forum and the enthusiasm generated by the working group's report to make a difference at the country level by moving from recommendation to action.

Universal health coverage: friend or foe of health equity?

As the importance of quality in health care provision is increasingly recognised, it is opportune to consider quality care as a key link between clinical and public health approaches to human immunodeficiency virus (HIV) infection in developing countries, especially in sub-Saharan Africa. This region has the lion's share of the global epidemic and the least resources to respond. Looking at health problems using a 'quality lens' may help bridge the gaps between clinical care and public health, the current and desired standard of care, and prevention and treatment. Quality care, with prompt diagnosis and effective treatment, of people with HIV infection is crucial for good individual health outcomes, public health outcomes (in terms of decreased HIV transmission) and societal outcomes (increased productivity and decreased costs of health provision for HIV-related care). A spotlight on quality care can bring clinicians and public health practitioners together in working towards universal access to quality HIV care and prevention - one of the greatest health challenges faced in developing countries in Africa today.

There is an increasing body of evidence of a strong correlation between the density of trained health workers in a country and improved population health outcomes. Yet many countries lack sufficient numbers and equitable distribution of skilled health workers to deliver essential health interventions, such as immunization and skilled attendance at delivery. The World Health Organization estimates that there are 57 countries, mostly located in sub-Saharan Africa, with crisislevel shortages of doctors, nurses, midwives and other health workers (WHO, 2006). An increasing number of stakeholders – including international and national agencies, non-governmental organizations and the general public – have become sensitive to the importance of planning, developing and strengthening the health workforce in order to meet national and global health and development goals, including the healthrelated Millennium Development Goals. With only five years left until the 2015 deadline to achieve the Millennium Development Goals, 2010 presents a critical opportunity for action to increase investment and support to countries to strengthen their health systems, including their health workforce, to deliver primary health services. Despite the undoubted importance of monitoring the health workforce and impacts on population health outcomes, the empirical evidence to support policy formulation is often fragmented. Many sources can potentially produce information relevant to this issue but remain underused in health research, especially among lowand middleincome countries. Falling into this category are national population censuses. Population censuses with questions on labour force activity and occupation can be a key source for statistics describing the health workforce, providing a comprehensive snapshot of the stock and distribution of health workers in a country (GUPTA et al., 2003; LAVALLEE, et al., 2009). However there are few (if any) documented experiences of health sector planners, managers and policy-makers capitalizing on this resource to inform decision making. In most cases, ministries of health rely exclusively on administrative data sources such as facility staffing records and registries of professional regulatory bodies. While these sources offer many advantages compared to populationbased sources, including being locally available and generally easy to use among non-specialist audiences, having and using a range of data from different sources can help present a fuller picture and minimize the risk of making decisions based on statistics that are incomplete or biased (ABOUZAHR et al., 2007). In Brazil, like many other countries, population censuses are conducted about once every ten years. The last census for which data are currently available, conducted in the year 2000, included questions on occupation among household members of age of economic activity. The coding of responses, as mapped to the national classification of occupations, allowed for statistical delineation and analysis of those with a health-related occupation, such as medical doctors, nutritionists and nursing auxiliaries. As in many other countries, the national classification holds as reference the International Standard Classification of Occupations (ISCO).