Next week, WHO’s Executive Board will discuss the draft Global Strategy on human resources for health: Workforce 2030. If all goes well, the final version will be endorsed at the 69th World Health Assembly in May. Workforce 2030 provides a new and progressive health workforce agenda.
A decade ago, The World Health report 2006 already estimated a global shortage of 4.3 million health workers. Since then, the Global Health Workforce Alliance has tried to address the HRH governance challenges, albeit with a mixed impact. A major reason for this is that governments have not made, or were not in the position to make considerable additional investments in the health workforce. There were some notable exceptions, including in Low and Middle-Income Countries (LMICs), but in general the outcomes have been below expectations. Both within domestic and international health financing, recurrent expenditure (salaries and education) for health workers has lagged behind other health investments.
The new Sustainable Development Goals (SDGs) include as target 3c. ‘Substantially increase health financing ……of the health workforce in developing countries….’. Workforce 2030 uses a new benchmark indicator, the so called SDG composite method (see annex 1 of the Global Strategy). It estimates that 4.45 health workers per 1000 population are needed to reach the SDG health targets. This amounts to a total global deficit of 17.6 million health workers relative to current supply, with a projected deficit of 13.6 million health workers in LMICs alone.
Workforce 2030 is a strong building block for integrating health workforce development in broader health and socio-economic development. However there is an ambiguity underlying the strategy that merits attention, not unlike the one in the overall SDG agenda: social development still relies on the old model of (industrial) economic growth.
‘Workforce 2030 makes the case that investment in the workforce offers a triple return; social- and economic benefits, improved health outcomes and robust front-line defense for global health security’. (par.9)
Health equity will be at risk in this approach. The strategy relies on the assumption of (strong) economic growth in LMICs to finance workforce deficits. The global additional wage bill needed to scale up the workforce in LMICs is considerable. A major question is: who is going to finance that bill? Will domestic revenue suffice or will this be a shared responsibility, with also an international financial framework?
Workforce 2030 argues for public sector intervention to ‘recast insufficient provision of health workers and their inequitable deployment’ and public HRH investments should be supported by ‘appropriate macro-economic policies’ while ensuring ‘adequate fiscal space’ (par.38) The next paragraph mentions ‘expected growth in health labour markets …as a way to create qualified jobs’ (Par.39).
The crux is that the prevailing, resilient macro-economic model (the ‘Washington consensus’) has led to fiscal contraction, austerity measures across the globe, privatization of services, liberalisation of trade and capital, deregulation of labour markets etc. Although the Washington consensus has been criticized by some national governments and others, key tenets of it are still very dominant with impacts visible worldwide.
Emerging economies like Brazil face serious economic difficulties while the expected growth in many African countries seems overestimated. It is a fallacy and a myth to believe that such a monetarist economic model and the “labour market” will overcome the workforce deficits, and improve health outcomes. Privatization of education and health services will indeed create highly skilled, professional, medical staff, but these will be only accessible for those who can afford them (e.g. via health insurance schemes). This will stimulate further (global) mobility of the skilled medical workforce while limited public funding and philanthropy will need to cover other public health functions as well as the deployment of lesser skilled Community Health Workers (CHWs) to impoverished neighborhoods and rural areas. CHWs are essential for integrated, people-centred health services but the scenario above leads to parallel systems; access to a skilled medical professional for those who can afford it, poor services for the ones that rely on minimum health coverage.
The good thing is that there are alternative pathways if we dare to imagine and attempt them. A key advice for Workforce 2030 and the actors working on it would be to de-emphasize the instrumentalist, utilitarian role of the health workforce in economic growth and labor markets, and rather emphasize the intrinsic value of a competent workforce in improving health outcomes and reducing health inequalities. Inspiration can be sought from those that already aim to transform economic performance and policies, and consider them as a means towards social and health outcomes, rather than as the goal. In this scenario, Health workforce 2030 would not merely be a technical program or leading to yet another global health initiative. It could become part of a wider social and political project of which the time has come. Then, Health workforce 2030 would be a truly progressive agenda that could help to transform the current global health paradigm.