This week marked a historic moment for the global health workforce community. The High-Level Commission on Health Employment and Economic Growth, chaired by France’s President François Hollande and South-Africa’s President Jacob Zuma, delivered its final report and recommendations to UN Secretary General Ban Ki Moon on the sidelines of the UN General Assembly in New York. The report represents a major milestone for those working on health systems development. The new health workforce agenda is connected with other key development objectives, including inclusive economic growth and decent work for all. In addition, the report provides a firm link with the SDGs on education and gender equality. Richard Horton (chair of the expert group on HEEG) put it like this on Twitter,: “It’s not the usual self-regarding advocacy for health. This is about a radical transformation in our vision for health in society.”
Ten recommendations (six on transforming the workforce, four on enabling change) are outlined in the High-level Commission report (supported by an expert group report providing the evidence). A new global momentum towards investing in the health workforce is now obvious. Moreover, the inter-sectoral collaboration between the multilateral agencies WHO, ILO and OECD, as well as the strong political support by the commissioners and chairs positions the health workforce as crucial to the global development process.
One of the key messages, backed by significant evidence, is that the health workforce shouldn’t be regarded as a cost, but as an investment with a triple return – for health, economic growth and global health security. The returns on investment in health are estimated to be 9 to 1. Job creation in the health sector might also help improve social protection and cohesion, and provides an attractive pathway for women’s economic participation and empowerment. On the whole, the sector needs to reform to prioritize primary care and people-centered health systems, respond and detect public health risks emergencies, and embrace new information and communication technologies.
The report reflects the urgency of the need to invest in the health workforce; evidence points towards a projected shortfall of 18 million health workers, primarily in low- and lower-middle income countries by 2030, unless additional investments are made. To address this considerable policy challenge, the report offers four powerful recommendations. The first, and perhaps most important one, is to address the issue of political commitment, critical to generate sufficient funding from both domestic and international resources. While there is moderate optimism about increasing fiscal space in lower-middle income and middle-income countries and its potential for (more) domestic investments in the health workforce, there is also a strong call for collective action and international financing to invest in health jobs in low-income and fragile states. The second recommendation concerns the promotion of inter-sectoral collaboration at national, regional and international levels. The third one is on international health workforce migration– a trend that will likely increase further. The Commission calls for an updated broader international agreement on health workforce mobility, with lessons to be adapted from the Paris Agreement on Climate Change, including provisions for resource transfers and investments in capacity building of health workers to ensure the sustainability of health systems in source countries. The fourth recommendation is on strengthening data, including an appropriate global framework for independent accountability across the SDGs, and data exchange managed by the Global Health Observatory.
There is now a global framework for the health workforce agenda with five immediate strategic actions to be taken. A first step will be the organization of a summit in December 2016 at the WHO to develop a five-year implementation plan for the ten recommendations.
While I am in general enthusiastic about this global HRH policy framework and the political momentum it has created, I would like to add to some words of caution on its implementation.
First, there is a need to think through the quality of the economic growth that is to be obtained. The rationale behind the report is based on social-liberal ‘New Deal’ policies and Keynesian economics that argue for government intervention and investment during recessions. Nobel Prize winning ‘New Keynesian’ economists like Paul Krugman and Joseph Stiglitz adhere to principles of fiscal expansion to foster demand in the economy. David Stuckler argues in the (highly recommended) book ‘The Body Economic: Why Austerity Kills’ why public investments in the health system in times of recession are so crucial. While these Keynesian interventions provide a necessary levelling ‘antidote’ to the excesses of transnational capitalism, more structural macroeconomic and political interventions will be required to regulate transnational finance and its devastating effect on global income equality. The democratic sovereignty of states to intervene in their own economies has been considerably diminished in our times of ‘deep globalization’. It is hence important that the health, labor and growth market agenda is connected with SDG10 on reducing inequalities, which among others requires the democratization, regulation and monitoring of global financial markets and institutions. Moreover, development economists argue that, in a carbon-constrained world, we must ‘shift our attention from global economic growth itself, towards improving the distribution of the benefits of global production and consumption ’.
Second, the current international health landscape shows fierce political competition and disagreement between states and other actors on priority global health issues. For sure, a strong health workforce is critical to achieve global health objectives such as UHC, Women and Child health, Global health security and the need to tackle Antimicrobial Resistance. With many of these health issues now part of high politics and foreign policy (see the growing attention for global health at the UNGA) one also needs to consider the discourses, agency , alliances and powers that put these issues on the agenda and examine why action on them is pursued (or not). Developing the workforce requires committed investments, a longer timeframe and sustained political engagement. States are, however, under (political) pressure to demonstrate that ‘any money invested in global health (e.g. in GF, GAVI or WHO) must directly lead to progress’.
Hence, considerable health diplomacy will be required by all actors (state and non-state ones) involved in the global workforce movement to seek synergies with other global health issues and to keep the health workforce on the (political) agenda.
Let me end with the concluding words of Guy Ryder, Director-General of the International Labour Organization, during the launch event at the UNGA this week:
“There is no time for complacency. We have a considerable agenda ahead to mobilize the international political and financial support. We will have to face major issues such as the sensitive issue of health workforce migration and its governance “.
As I have been working on health workforce policies since a long time, it is encouraging to see that the health workforce has – at last – become a prominent element of the global health revolution.