As the Reachout consortium reminded us in a series of well tweeted-about presentations at Prince Mahidol Award Conference (PMAC) 10 days ago, community health workers (CHW) need to be a centerpiece of human resource for health (HRH) policies targeting health equity, effectiveness and efficiency via universal health coverage (UHC). Their work is a timely reminder of a point I made in my last IHP blog which is that the expansion of CHWs or cadres of ‘close-to-community’ health workers will be critical for overcoming the chronic insufficiency and maldistribution of human resources for health in many low- and middle-income, as well as a number of high-income, countries.
Why have I returned to this issue? In part to draw attention (again) to the need for deep engagement by global health advocates, practitioners, researchers, and policy makers (i.e. us), with the complexity of designing and making operational HRH and CHW policies. I look at the extraordinarily high level and the sustained nature of engagement by international and national policy makers on the issue of national health insurance design & implementation, and I find it curious that the same level debate has not emerged in relation to enhancing HRH or scaling-up CHWs schemes. These health workers, will, after all, be the mainstay of actually delivering services that any national health insurance scheme pays for. And the service coverage and quality components of UHC will be directly associated with the sophistication and contextual fit of the HRH policies in play.
Perhaps we need a Lancet Commission with Horton-style advocacy to make this issue sexier and drive the sort of ‘glamour-engagement’ that ensures a spot on the mainstream (rather than semi-peripheral) global health agenda.
I wanted to take a moment to draw out the comparison between the ‘dialogue’ on national health financing versus HRH and CHWs, spurred in part by Michael Reich and colleagues’ analysis of 11 countries’ progress towards UHC. In re-reading this article, it struck me how across a raft of countries, progress towards UHC-oriented national insurance schemes was typically achieved via incremental steps in a kind of a ‘work-with-what we’ve-got’ approach. That is, national health insurance schemes evolved (either via expansion, or consolidation of more targeted schemes) from existing, less comprehensive health insurance policies. The article also neatly summarises the deep and broad analysis (predominantly domestically-led) that has underpinned this progress – as countries grapple with the questions of who should be covered, where the money will come from, how it will be collected and re-distributed and the implications that different combinations of each of these have for the goal of UHC.
Sounds sensible? It is. This process also speaks to a key feature of policy design in complex systems – namely the need to understand, and work with, historical decisions and processes while accounting for various dynamic interactions between current political, social and economic features that influence the efficacy of any given reform. Moreover, in the cut-and-thrust of such analysis and debate we see facilitation between potentially conflicting interest groups and the adjustment and reform of appropriate governance mechanisms to boot.
We in global health need to up our game when it comes to the chronic emergency of HRH. And while far from flawless, the simultaneously high-level and broad and deep nature of the UHC-inspired national health financing dialogue does provide one example. It is no longer sufficient or even helpful to consider HRH policies in terms of their ‘recruitment’ or ‘retention’ siloes. Nor, as the health financing example shows us, does it seem particularly useful to rely on well-meaning but ultimately high-flown global strategies in the absence of more robust and contextualized domestic debates that will account for the reality on the ground. We do need a broad-ranging conversation – and one with sustained high-level sponsorship such as that provided by Global Health Workforce Alliance – but that conversation must welcome, not avoid, the messy and heterogeneous reality of existing policies, structures, institutions and norms that frame different countries’ approach to health worker recruitment and retention, organizational culture and quality improvement, and formal and informal regulatory and incentive mechanisms. Like the health financing dialogue, moreover, these elements must be considered concurrently in order to design (country-by-country) HRH policies that not only work with what we’ve got but that also make the best of it.