The seven sins and the seven virtues of Universal Health Coverage

Universal Health Coverage is likely to become the backbone on which the health development agenda beyond 2015 will be constructed. To avoid unintended effects, Universal Health Coverage should keep away from committing seven sins and should try to practice seven virtues.

Backed by most actors in the global health scene, Universal Health Coverage (UHC) is likely to become the mantra that will drive health transformations for years to come and the backbone on which the health development agenda beyond 2015 will be constructed. There is now widespread agreement on the need to extend access to health care to all individuals and populations, as illustrated by UN statements (1), WHO reports (2), and a number of articles in medical journals, including a Lancet series (3). The call for UHC comes at a time when, after decades of neoliberal policies, privatization of health care services has reached a peak leading in many countries to further exclusion and/or catastrophic expenditures. To help reverse this trend, however, and to avoid unintended effects, UHC should keep away from committing seven sins and try to practice seven virtues.

1. Sloth (failure to do things that one should do and to make the most of one’s talents and gifts) vs. Diligence (upholding one’s convictions at all times, especially when no one else is watching)

To many people, UHC may sound like Health for All (4). However, what is currently proposed differs substantially from what was proposed in Alma Ata. Primary health care intended to transform health systems, as opposed to health care systems, within a broader social transformation. The signatories of the Declaration were aware of the importance of the social determinants of health well before the report of the WHO Commission (5). Primary health care included education, nutrition, water and sanitation, in addition to essential health care. Unless UHC is served with an extensive dressing of primary health care and social determinants of health, i.e. unless it is implemented within a framework of social and economic transformation, it will not transform health as profoundly as hoped. Paradoxically, an excessive focus on UHC could divert attention and resources from other sectors with a bearing on health (6).

2. Greed (inordinate desire to acquire or possess more than one needs) vs. Charity (benevolent giving and caring, solidarity)

To some people, UHC may seem to be synonymous of health insurance schemes that would fund a limited package of services, with governments playing a range of different and often minimal roles. The equation of UHC with financial coverage is implied also in the title of the WHO World Health Report for 2010 (7). Such an interpretation of UHC focuses on the mere element of affordability, or economic accessibility. It may pave the way to a massive infiltration of the private sector into health care systems that in some countries are still mostly public, and it may undermine the efforts of those countries that have undertaken reforms towards a stronger public sector. To avoid this, UHC should aim at increasing the proportion of health care services that are mastered and managed by the public sector (8), and financed by progressive taxation systems. In places where the private sector is prevalent and likely to remain so for a long time, governments should strongly regulate it, especially as far as quality of care and lucrative attraction for health professionals are concerned, while progressively investing to reinforce the public sector (9). Also, UHC should be robust enough to accommodate new challenges, e.g. the new burden brought about by the changing epidemiology of non-communicable diseases (10), and to resist the downwards swings brought about by present and future economic and financial crises (11). Ad hoc goals and targets on access to the public sector should be developed if UHC is included in the post-2015 development agenda.

3. Gluttony (over-consumption of anything to the point of waste) vs. Temperance (self-control, abstention, moderation)

Trade mechanisms will keep influencing the delicate balance between demand for and supply of health care services. Given the well known asymmetry of information between providers and users in this atypical market, UHC should include mechanisms aimed at moderating any inappropriate excess of supply that in turn may end up in increasing demand. Historically, this point has been pointed up by Ivan Illich: “although physicians did pioneer antisepsis, immunization, and dietary supplements, they were also involved in the switch [from breastmilk] to the bottle.” (12) Currently, demand may be artificially inflated by the push for new pharmaceutical or technological solutions to real or presumed health needs, in what is known as disease mongering (13). Moreover, due to the liberalization of global trade, the associated dissemination of unhealthy lifestyles, the aggressive marketing of health care products, the drive towards increasing consumption and waste, the legal obligations brought about by global trade treaties, and the lack of public regulations to protect public health, demand may rise above the capacity of health care systems to respond, creating imbalances that are difficult to address and that would be an obstacle to UHC itself (14).

4. Pride (failure to acknowledge the good work of others) vs. Humility (thinking of oneself less in a spirit of self-examination)

UHC will positively affect health only if due attention is paid to its quality. Quality care is the delivery of safe and effective interventions in ways that, by taking into account the needs and the background of users and their communities, ensure the best possible outcomes to all. Quality of care has only recently been recognized as a neglected issue in the international health agenda, particularly as far as care around childbirth is concerned (15,16). Several studies and reports indicate that quality may be far from acceptable, thus jeopardizing the ultimate aim of health services. Delivering care which is not technically sound implies increasing the costs for the system and households without achieving health. Improving quality, however, implies no less difficulty than increasing access. A variety of approaches have been proposed, but reports of successful quality cycles are scanty. Efforts to improve paediatric quality of care in district hospitals through systematic standard-based peer-review assessment have been successful, particularly when action at facility level is combined with action at national health system level, through introduction of national standards and improvement in all the building blocks of the health system (17). The tool for paediatric care developed by WHO, and the equivalent maternal and neonatal assessment tool, are able to identify quality gaps and prompt quality cycles at local level and systemic action at national level (18,19). Market mechanisms alone, like those described by proponents of health insurance reforms (20), are unlikely to have a sustained effect on quality of care.

5. Envy (desire to deprive other people of their abilities or rewards) vs. Kindness (empathy and trust without prejudice or resentment)

Health is a complex adaptive system within wider cultural, social and economic complex adaptive systems.21 Changes in access to health brought about by UHC are likely to affect other building blocks within the health system, the training and distribution of the health workforce for example, or in other social sectors, the transport system for example.

Needless to say, the reverse is also true. A systems thinking approach is compulsory to try and predict the effects that modifications of the health system may have on other complex adaptive systems, and viceversa (22). Parallel to UHC, capacity for a systems thinking approach should be built among policy and decision makers, as well as planners and researchers. This would be easier if UHC was integrated into a wider social protection framework (23). To avoid increasing the gap between the better and the worse off, coverage and social protection should be preferentially provided to the latter group, at least initially (24). This would be particularly important in places where financial risk protection and health insurance have proven to be difficult to implement and scale up, e.g. in remote contexts and poor, underserved communities.

6. Wrath (impatience, revenge and vigilantism) vs. Patience (creating a sense of peaceful stability rather than hostility and antagonism)

The implementation of UHC, with all its corollaries of principles, policies, activities and constraints has to be properly governed and monitored. Governments will obviously be in charge of it at national and local levels. But who will be in charge of its governance at global level? The WHO is the natural candidate, but in recent years it has failed to provide an effective and coherent leadership based on the principles of the right to health for all. Critical budgetary and organisational constraints, including donor dependence, contradictions in the management of human resources, excessive decentralisation and lack of accountability to member states, weaken the role of WHO in global health governance. The current process of reform suffers from many of the very problems that it is meant to address, and may fail to re-qualify WHO for the governance of global health (25). However, there are possibly no alternatives to a strengthened normative role of the WHO as advocated by Chen and Berlinguer a decade ago (26). With patience, and courage, WHO could lead the development of new ad hoc regulatory frameworks, modelled on the Framework Convention on Tobacco Control. A strong alliance with civil society organizations that look after the public interest and identify global health as a common good would be an asset. While the authority of WHO and its treaty making power remain necessary, the potential role of bottom up strategies involving community participation should be also acknowledged. By encouraging social empowerment, increasing the potential to strengthen health systems at local levels, organizing demand for services prioritized by communities, and linking generation of knowledge to its use in action, strategies such as participatory action research and community based monitoring are increasingly recognised as key elements towards UHC (27).

7. Lust (intense desire of money, fame or power) vs. Chastity (to be honest with oneself, one’s family, one’s friends, and to all of humanity)

Finally, UHC should be spelled out and positioned within a human rights framework. The Universal Declaration of Human Rights and the International Covenant on Economic, Social and Cultural Rights clearly state that the fulfilment of the human right to health relies on the fulfilment of other rights, e.g. food, housing, work, education, non discrimination, participation and freedom of association. More in detail, the International Covenant states that while “the right to health is not to be understood as a right to be healthy”, it is “an inclusive right extending not only to timely and appropriate health care but also to the underlying determinants of health”, and adds that “a further important aspect is the participation of the population in all health-related decision-making at the community, national and international levels.” (28) It states also that “The right to health [care] in all its forms and at all levels contains the following interrelated and essential elements”: (a) availability, (b) accessibility in its four overlapping dimensions: non-discrimination and physical, economic (affordability) and information accessibility, (c) acceptability, and (d) quality of services. Unless the international community pushes the right to health up in its scale of values and stops considering health as a dependent variable of the global economy, and unless it makes the respect of human rights mandatory and those who violate them legally accountable, UHC is unlikely to yield the expected results.

To conclude, the incorporation of the UHC concept in the post-2015 development agenda should aim at maximizing benefits and minimizing harm. This can be achieved only if all the above criteria are met and built into UHC, with enforceable mechanisms to hold governments accountable. In particular, UHC should be understood as a way to ensure the right to health. Only within a human rights framework UHC would benefit from a comprehensive approach, as opposed to the fragmented, vertical approach entrenched in the health (insurance) coverage approach with multiple actors either on the payer or on the provider side that focus on personal, mostly disease-centred and curative services. Addressing UHC in a human rights framework will help re-position the right to health in the context of the post-2015 development agenda.

Authors: Adriano Cattaneo, Giorgio Tamburlini, Angelo Stefanini, Eduardo Missoni, Gavino Maciocco, Gianni Tognoni, Carlo Resti, Claudio Beltramello, Chiara Bodini, and Nicoletta Dentico, Italian Global Health Watch. Correspondence: Adriano Cattaneo, Androna San Fortunato 8, 34136 Trieste, Italy. E-mail: adriano.cattaneo@gmail.com 

References

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5. WHO Commission on Social Determinants of Health. Closing the gap in a generation. Health equity through action on the social determinants of health. WHO, Geneva, 2008
6. Joint statement of the UN Platform on Social Determinants of Health. Health in the post-2015 development agenda: need for a social determinants of health approach. United Nations, New York, 2013.
7. World Health Organization. Health systems financing: the path to universal coverage. The world health report 2010. Geneva, 2010.
8. Sachs JD. Achieving universal health coverage in low-income settings. Lancet 2012;380:944-7.
9. Jan Swasthya Abhiyan. Universalising Health Care for All. Amit Sengupta, New Delhi, 2012.
10. Dye C, Mertens T, Hirnschall G, Mpanju-Shumbusho W, Newman RD, Raviglione MC et al. WHO and the future of disease control programmes. Lancet 2013;381:413-8.
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12. Illich I. Medical nemesis: the expropriation of health. Pantheon Books, New York, 1976.
13. Moynihan R, Doran E, Henry D. Disease mongering is now part of the global health debate. PLoS Med 2008;5:e106.
14. Missoni E. Understanding the impact of global trade liberalization on health systems pursuing universal health coverage. Value Health 2013;16:S14-S18.
15. van den Broek NR, Graham WJ. Quality of care for maternal and newborn health: the neglected agenda. BJOG 2009;116 Suppl 1:18-21.
16. Graham WJ, McCaw-Binns A, Munjanja S. Translating coverage gains into health gains for all women and children: the quality care opportunity. PLoS Med 2013;10:e1001368.
17. Campbell H, Duke T, Weber M, English M, Carai S, Tamburlini G. Global initiatives for improving hospital care for children: state of the art and future prospects. Pediatrics 2008;121:e984-e992.
18. Duke T, Keshishiyan E, Kuttumuratova A, Ostergren M, Ryumina I, Stasii E et al. Quality of hospital care for children in Kazakhstan, Republic of Moldova, and Russia: systematic observational assessment. Lancet 2006;367:919-25.
19. Tamburlini G, Siupsinskas G, Bacci A. Quality of maternal and neonatal care in Albania, Turkmenistan and Kazakhstan: a systematic, standard-based, participatory assessment. PLoS One 2011;6:e28763.
20. Lagomarsino G, Garabrant A, Adyas A, Muga R, Otoo N. Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia. Lancet 2012;380:933-43.
21. Swanson RC, Cattaneo A, Bradley E, Chunharas S, Atun R, Abbas KM et al. Rethinking health systems strengthening: key systems thinking tools and strategies for transformational change. Health Policy Plan 2012;27 Suppl 4:iv54-iv61.
22. de Savigny D, Adam T. Systems thinking for health systems strengthening. WHO, Geneva, 2009.
23. Cecchini S, Martinez R. Inclusive social protection in Latin America: a comprehensive, rights-based approach. Economic Commission for Latin America and the Caribbean, Santiago, Chile, 2012.
24. Gwatkin DR, Ergo A. Universal health coverage: friend or foe of health equity? Lancet 2011;377:2160-1.
25. Legge D. Future of WHO hangs in the balance. BMJ 2012;345:e6877.
26. Chen LC, Berlinguer G. Health equity in a globalizing world. In: Evans T, Whitehead M, Diderichsen F, Bhuiya A, Wirth M, editors. Challenging inequities in health: from ethics to action. Oxford University Press, New York, 2001: 35-44.
27. Loewenson R, Flores W, Shukla A, Kagis M, Baba A, Ryklief A et al. Raising the profile of participatory action research at the 2010 Global Symposium on Health Systems Research. MEDICC Rev 2011;13:35-8.
28. United Nations Economic and Social Council. The right to the highest attainable standard of health (E/C.12/2000/4). United Nations, New York, 2000.

Competing interests: No financial conflicts of interest; no funding was sought for writing the paper. Adriano Cattaneo was employed by WHO between 1990 and 1994 and has subsequently coordinated a WHO Collaborating Centre. Claudio Beltramello was employed by WHO between 2001 and 2003. Giorgio Tamburlini has coordinated a WHO Collaborating Centre and continues to work as a free lance consultant for WHO and other agencies. Angelo Stefanini, Eduardo Missoni, Gianni Tognoni and Nicoletta Dentico were also involved with WHO activities at various levels and at different times. Angelo Stefanini and Chiara Bodini collaborate with the People’s Health Movement.

WHO Global Code of Practice - lost in translation?

The “WHO Global Code of Practice on the International Recruitment of Health Personnel” was adopted by the World Health Assembly, in May 2010. Three years later, back in Geneva at the World Health Assembly, it looked as if the Code has gone lost somehow in its translation from paper to practice.

By Thomas Schwarz

Back from this year’s World Health Assembly (WHA) in Geneva, I have mixed news and mixed feelings about the implementation of the “WHO Global Code of Practice on the International Recruitment of Health Personnel” (1), a topic that was on the WHA agenda, with a report (2) by the WHO Secretariat to be “noted” by the member states of the World Health Organization.

The background: Over 50 countries, mainly in Africa and South Asia, suffer from a critical shortage of health personnel. And in the aging societies of European countries, the number of people who need long-term care is increasing the demand for health workers. As the labour market becomes more globalized, the rising demand for staff is driving migration and mobility amongst health personnel. The recruitment of health workers from abroad and the related “care drain” of doctors, nurses and other health workers increases existing inequalities and further weakens weak health systems.

In 2010, such analysis (3) led to the adoption of the WHO Global Code of Practice by the World Health Assembly. Three years later “we still require at least an additional 4.3 million health workers. Still, one billion people world-wide will never see a health worker in their life. So, three years after Code adoption and having the Code on the WHA agenda again: Let us take stock.” This is how Anke Tijtsma, Wemos, introduced a civil society side event to the World Health Assembly (4) organized by the Medicus Mundi International Network and the European “Health workers for all and all for health workers” project together with a great number of civil society partners and co-promoters such as the delegations of the EU, USA, Switzerland and Malawi to the WHA.

The event was attended by over 80 WHO Member States delegates, WHO staff and civil society delegates. Starting with case stories of Code implementation, country leadership and civil society involvement from source and destination countries and regions, the event led to a general discussion and overall conclusions on the state of Code implementation and the management of health personnel migration. As Marie-Paule Kieny, Assistant Director General of the WHO, admitted, progress in Code implementation is “painfully slow”. But what are the reasons that “stoking up the fire for Code implementation” has become such a challenge?

“International recruitment of health personnel”

Do you live in a country that faces a serious health workforce crisis? And, if yes, do you think that international recruitment is a key factor for this situation? Or would you say that action is rather required in fields such as the following:

• establishing effective health workforce planning, education and training, and retention strategies;
• strengthening educational institutions to scale up the training of health personnel and developing innovative curricula to address current health needs;
• adopting measures to address the geographical maldistribution of health workers and to support their retention in underserved areas;
• adopting and implementing effective measures aimed at strengthening health systems, continuous monitoring of the health labour market, and coordination among all stakeholders in order to develop and retain a sustainable health workforce responsive to the population’s health needs;
• adopting a multisectoral approach to addressing these issues in national health and development policies.

And do you expect international cooperation to support these processes in your country by providing effective and appropriate technical assistance, support for health personnel retention, social and professional recognition of health personnel, support for training that is appropriate for the disease profile of a country, twinning of health facilities, support for capacity building in the development of appropriate regulatory frameworks, access to specialized training, technology and skills transfers, and the support of return migration, whether temporary or permanent?

You know what? It is all in the Code! This whole list of strategies is directly quoted from it. The “WHO Global Code of Practice on the International Recruitment of Health Personnel”, despite its name and besides more specific sections dealing with international migration and recruitment, provides an overall roadmap for health workforce development. And, more important, this roadmap was agreed and unanimously endorsed by all WHO member states in 2010.

One of the biggest problems with the Code is its title. A simple solution would be to just informally re-label and promote it as “WHO Code of Practice on addressing the health workforce crisis”. In the words of Amani Siyam from the WHO Secretariat: “The Code is a planting bed for many good seeds of change. Just read it again!”

What cannot be counted does not count...

Dealing with the global health workforce crisis in a systemic and comprehensive way, as proposed by the Code, and promoting good practice in various fields related to developing and retaining a sustainable health workforce has its risks. Health systems are something “complex”, not easy to deal with. But national policy makers and international agencies and donors prefer more simple proposals: simple, easy to implement and internationally funded programs with clear, measurable and time-bound targets.

What cannot be counted does not count... and risks neither getting sufficient attention nor funding. The spirit of our time not only led to the Millennium Development Goals (and probably their successors), but also to some really strange global health initiatives such as “One million community health workers in sub-Saharan Africa by the year 2015” (5). If it was that easy...

What is simple is wrong, but what is complicated is useless. Criticising unsustainable quick fix solutions does not prevent us from admitting that one key strategy to address the health workforce crisis is if fact scaling-up and transforming health workers education, within a strong health system and based on sound regulation.

At this year’s World Health Assembly, having followed the rather uninspired official debate in WHA Committee B on the implementation of the Code, it took me really by surprise that the same Committee adopted, in an ad hoc exercise (or call it as a result of “guerrilla diplomacy”) led by Thailand and supported by many countries suffering from a health workforce crisis, a resolution on “Transforming health workforce education in support of universal health coverage” (Resolution WHA66/23). (6) The resolution, also referring to the Code, urges WHO member states “to further strengthen policies, strategies and plans as appropriate, through intersectoral policy dialogue among the relevant ministries that may include ministries of education, health and finance, in order to ensure that health workforce education and training contribute to achieving universal health coverage”.

This does not sound so bad, does it? And I was there in Geneva, focusing on Code implementation, and not aware of what happened next to me. And it would have been so logical: the focus of this year’s World Health Assembly and of much current global engagement in health is on universal health coverage. So it makes sense that health workers are identified as a central element of that policy and that the UHC hype is used to refocus attention on the health workforce crisis.

In fact, it makes sense to link the promotion of the Code with the efforts for scaling up and transforming health workers education – and, why not, with the current global push for achieving universal health coverage. If we focus too much on a particular aspect of the health workforce crisis (migration and recruitment OR education) and the related policies and strategies, we get lost in fragmentation. So rather let us admit, that, in its core, it is all about the same. Let us leave our silos and realize that are stronger walking together.

Code adopted - everything (nothing) achieved

At the civil society side event to the World Health Assembly various speakers stated that, after the tough negotiations before and during the 2010 WHA, the adoption of the Code was for many the end of something instead of its beginning: At that moment, there was great enthusiasm, but no preparedness to work with the Code, and no proper mechanisms in place for its implementation. And it also rather looked then as if those who promoted the Code considered the mission as accomplished and dropped or downgraded the issue afterwards. This was at least how the drastic staff cuts at the HRH unit of the WHO Secretariat in 2011 were seen from the outside.

You can also see this point differently: During the elaboration of the Code in 2010 the language was diluted in that the mention of compensation to source countries for the costs incurred in the formation of emigrated health workforce was removed. So, when the Code was adopted, it might be that those countries that expected cash were not happy just to get just kind (words).

Anyhow, mobilization of stakeholders, including civil society, for Code implementation remained poor in most of the regions and countries. This is definitely bad news, as Yoswa Dambisya stated in an editorial published right after the World Health Assembly. He referred to the International Code of Marketing of Breast-milk Substitutes adoped by the WHA in 1981 (7) and whose implementation is still a great success: “This provides a lesson on the role of civil society to galvanise countries into action, particularly with technical support of WHO. Civil society has kept the code on breast milk substitutes alive and current and generated pressure within countries to ensure that it is implemented. Is this possible for the Code of Practice on International Recruitment of Health Personnel? In theory it is achievable. The loss of health workers in countries of highest health need is still a concern, and communities and health workers have an interest in the issue, as it affects their rights and services.” (8)

It is time to re-politicise the discussion on the devastating effects of lacking health personnel in poor countries and regions and on the global dimensions of the national health workforce crises. It is time to denounce and address the economic and political determinants of poor health and poor social protection, such as tax evasion and capital flight. Just read the great blog on “Human Resources for Health – a bottleneck for Primary Health Care?” (9) written by my colleague Remco van de Pas some days ago.

“It is everybody’s business to move ahead with the Code”

When Marie-Paule Kieny, Assistant Director General of the WHO, expressed the greetings of the WHO Director General to the participants of the civil society side event, she said that civil society involvement in the follow-up of the implementation of the Code was well acknowledged by WHO. There was also a lot of praise for the European civil society organizations that reported last year at the WHO Europe meeting about Code implementation and the contributions of civil society in their countries (10) and recently set up the “health workers for all and all for health workers” project (11) for the further promotion of the Code implementation in Europe.

Marie-Paule Kieny concluded: “It is everybody’s business to move ahead with it.”

But what sounds encouraging can also be a problem: If everybody is responsible, nobody takes responsibility. If the number of countries speaking at the World Health Assembly under a specific agenda item is a measure, the Code failed: only 14 countries took part in the official discussion of the Secretariat’s report, and whole WHO regions such as Africa (represented by Burkina Faso) and Europe (represented by Ireland) confined themselves to weak general statements.

So it was good to hear from representatives of WHO and some countries that they are still committed to implement the Code and that there are in fact plans and perspectives to re-launch implementation at a higher level. These plans include concrete steps that make sense, such as:

• improving statistical tools for national health workforce planning and forecasting based on the OECD observatory;
• improving the “National Reporting Instrument”;
• organizing technical regional meetings.

Key elements not properly addressed by the World Health Assembly are the on-going lack of capacities at all levels and the problem that country information on Code implementation gathered since 2010 through the National Reporting Instrument developed by the WHO Secretariat is not openly accessible. (12)

Anyhow, even if it is “everybody’s business” to move ahead with the Code, the main responsible are the WHO and its member states. It is up to them to show committment, ownership and leadership on the Code. There is much at stake, as Switzerland stated at the Assembly: The successful implementation of the Code is a question of credibility of the WHO, especially as the Code is one of the few regulatory instruments developed and adopted by WHO over the last years. This directly refers to the statement by the European “health workers for all and all for health workers” campaign in the official discussion: “The success or failure of its implementation will be seen as a case study for the capacity of WHO – and its members – in the field of global standard setting and regulation. This links the technical issue of Code implementation with the overall issue of WHO reform and the role of WHO in global health governance.” (13)

Conclusion of the WHO Secretariat’s report to the WHA: “The health workforce crisis is a global, multidimensional challenge. It requires a comprehensive global strategy to transform the production of health workers, encompassing labour market analysis as well as the transformation of education and training of the health workforce, at national and transnational levels. It is essential that countries wanting to improve access to health care meet the challenge posed by shortages in the health workforce. Renewed approaches to the health workforce crisis will therefore be critical for moving towards universal health coverage.” - There is nothing to add to that one.

Basel, 12 June 2013,Thomas Schwarz, Executive Secretary of the Medicus Mundi International Network, host of the WHA civil society side event on Code implementation for the European project “Health workers for all and all for health workers” and a broad coalition of civil society partners and co-promoters.

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Notes

1. WHO Code of Practice: see http://www.who.int/hrh/migration/code/full_text/en/index.html
2. The health workforce: advances in responding to shortages and migration, and in preparing for emerging needs. http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_25-en.pdf
3. Quoted from the invitation leaflet for a civil society side event to this year’s World Health Assembly: WHO Global Code of Practice on the International Recruitment of Health Personnel: Stoking up the fire for Code implementation. Geneva, 22 May 2013, see www.bit.ly/wha66-code 
4. See above
5. One Million Community Health Workers until 2015 (this is NOT a satire) http://www.medicusmundi.org/en/mmi-network/documents/newsletter/201304
6. See http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_R23-en.pdf
7. See http://www.who.int/nutrition/publications/infantfeeding/9241541601/en/
8. No Universal Health Coverage without health workers: Putting the Global Code back into the spotlight. YM Dambisya in: Equinet Newsletter http://equinetafrica.org/newsletter/index.php?issue=148#1
9. Published in the MMI “Get involved in Global Health!" blog on 7 June 2013: http://getinvolvedinglobalhealth.blogspot.ch/2013/06/human-resources-for-health-bottleneck.html
10. Progress to date: actions by civil society. Chapter in the WHO Europe policy brief "Implementing the WHO Global Code of Practice on International Recruitment of Health Personnel in the European Region” discussed at a technical briefing during the WHO Europe Regional Commitee meeting in 2012.
    http://www.euro.who.int/__data/assets/pdf_file/0013/173020/BRIEF_NRI_annex_060912VeryFinal.pdf
11. See http://www.healthworkers4all.eu
12. Implementation of WHO Code of Practice: Leadership, accountability and capacities are key! Joint statement by Medicus Mundi International, the People's Health Movement and the European campaign "health workers for all and all for health workers" http://bit.ly/11sXMX4
13. See joint statement, above

Human Resources for Health – a bottleneck for Primary Health Care?

While preparing this paper, I have been thinking whether to use a more common approach to the topic, which would be to provide an overview of health workforce issues in relation to Primary Health Care (PHC) development, including shortages and determinants in many Low and Middle income countries (LMICs). Consecutively we could have a look to strategies in the past and present to overcome issues like the retention of health care workers, maldistribution of health personnel, limited capacity for the education of health workers and possibilities for a balanced response to health workforce migration. 

While I might touch upon some of these aspects later, I rather address the health workforce challenge from another angle, one that is called “Interrogating scarcity: how to think about resource scarce-settings” and described by Ted Schrecker in a 2012 article. [1] Basically, the notion of interrogating scarcity is that scarcity cannot simply be assumed as a given. In an interconnected world, globalization and scarcity are closely linked. Globalization is described in Schrecker's article as “a pattern of transnational economic integration animated by the ideal of creating self-regulating global markets for goods, services, capital, technology, and skills... This Market fundamentalism presumes that markets are the normal and natural basis for organizing almost all areas of human activity; and tends to define citizenship in terms of participation in markets, as a producer and (informed) consumer. Market fundamentalism is the value system at the core of contemporary globalization." Over the last 3 decades, the development of Primary Health Care and health systems have been permeated by this market fundamentalism, and strongly influenced by forces of transnational economic integration. There Is No Alternative, as we can read in Francis Fukuyama's The End of History?[2] Few countries have been trying to come up with alternatives, as we will see, with remarkable results for health outcomes.

What does this all have to do with Health Workforce Development? I must admit that I don't like the term Human Resources for Health, because this term indirectly degrades health workers to a production unit, or in WHO terms a - health systems block - that can be controlled and adjusted by government and market forces. Every health worker is a unique human being that in his/her way, has the potential to contribute to other people's health. WHO has in a sense also downgraded the term health worker. In its World Health Report 2006 (Working together for health), health workers are defined as “to be all people engaged in actions whose primary intent is to enhance health”. But then the report continues: “ However, the data available on health worker numbers are generally limited  to people engaged in paid activities, so the numbers reported in this chapter are limited to such workers”. It then further classifies two types of health workers: “health service providers” and “health management and support workers”.  To further narrow it down, the medical doctor, nurse and midwife are considered professional service providers. When WHO talks about shortage of health workers, it talks mainly about this last professional category. This calculation is based on a minimum threshold of health workers needed for skilled birth attendance and 80% measles coverage; coming to a “floor” of 2.5 health workers per 1000 persons. With this calculation 57 countries (of which 36 in Africa) are considered to have a “critical' shortage. To reach this minimum threshold in all the 57 countries, an additional 4.3 million health workers would be required.[3]  If we interrogate this scarcity, we should explore what its main determinants are.

Task Shifting?

There are sufficient persons available to work on health, although not directly professional educated. Why not work with them? Task shifting to less specialized cadre is an often proposed solution. Brazil has since the '90s good experience with integration of community health worker in their primary health programmes that are based on a more integrated approach whereby community based organizations are involved in decision-making about allocation of resources and in actions that address some upstream determinants of health at the local level. This approach was part of a broader and well-funded health policy. However, in many countries these approaches have remained fragmented, with limited political commitment, genuine participation and long term funding. NGOs, especially in relation to the HIV/AIDS epidemic in Sub-Saharan Africa, have worked enthusiastically with community health workers in relation to health promotion, Voluntary Counseling and Testing and home based care. Despite local successes, uptake by governments to have these “volunteers” integrated in sustainable national programs with proper remunerations and educations has remained limited. [4]  

One of the core reasons why the professional health workforce in many LMICs could not expand has been considerations of macro-economic origin. A good example is Thailand. In the late seventies/ early 80s, due to the social environment, there had been in 10 years a fourfold increase of doctors working in rural areas. Rapid economic growth and a government investment policy, started in the late 1980s, supported private hospital investment with a free flow of low-interest foreign loans, facilitated by the World Bank, and resulted in a rapid growth of the private health sector in the decade from 1988–1997. It created an internal brain within the Thai health system, a second one after an external brain drain from Thai doctors in the 1960s to the United States.[5]

Fiscal space

Over the last 3 decades there has been a strong push for macro-economic stability and growth in LMICs, by means of deregulation and privatization of the economy. Conditions by the World Bank and the International Monetary Fund (IMF) on investment loans and crisis funding, forced countries to open up their economy to foreign investments, as well as a reduction of public spending (austerity) and a strict ceiling on wage bills for public sector employees, such as health workers. The IMF recipe can be described as the shock doctrine (The rise of disaster capitalism) in analogy of the book by Naomi Klein[6]. In current Europe we see that these policies are not contained to LMICs, but that the European Central Bank (ECB), EU and IMF (known as the “Troika”) force countries as Greece, Portugal, Ireland and Spain to reduce their public spending considerably. 

What has been and is the impact on the health workforce?  In ex-communist countries in Eastern Europe there has been a 7 % reduction of doctors per capita in the nineties when its economies opened to the West, as were the numbers of dentists and hospital beds. The IMF in 2007 concluded itself that wage bill ceilings had been overused in its poverty reduction programs. In the period 2003-2005, 17 countries in Africa faced wage bill ceilings. All these countries, amongst which Malawi, Mozambique and Zambia, were and are facing serious health workforce shortages, worsened by the HIV/AIDS crises and health demands. Its public governments could not employ new health staff in that period, because of the ceilings (although the IMF argues that exceptions could have been possible for the health sector). Instead global health partnerships like the GFATM and the PEPFAR initiative provided funds for NGOs and Faith Based Organizations to provide health services in parallel to the public system, which employed the health workers with private and,  too often, short-term contracts.[7]  

In Greece, the current austerity plan approved by the Troika leads to a  reduction of 150.000 jobs in the public sector workforce between 2011 and 2015. The Troika has demanded that public spending on health should not exceed 6% of Gross Domestic Product, which leads to a decrease of 25% of medical doctors employed by the central social security fund, as well as 25% reduction in physicians’ wages. There has been a sharp increase in people that require care, but that could not receive it. In Catalonia, due to austerity closure of health care services and reductions in the number of hospital beds and working hours have been reported. In Portugal public sector employees' income were cut in 2011 and 2012. The expectation is that in Europe, with its free internal labor market, these wage imbalances might lead to an internal European brain drain[8] Indeed, in the Netherlands, with is ageing population in need of chronic care, we have seen Spanish nurses being recruited by agencies for chronic and auxiliary care services..

The ‘fiscal realities’ in many European countries have a serious impact on social programs and wellbeing. The austerity measures that should stabilize national government debts and budget deficits, as to remain attractive and trustworthy for foreign investors provide a smoke screen for real issues of economic scarcity. One such has been the bail-out in several European countries of too-big- to fail financial institutions with public financing. The de-regulation of the financial sector and the lack of accreditation by the governments of its banking products, is one the reasons why the crisis has hit so hard. We could perhaps learn from Iceland that in its 2008 crises decided not to bail out the banks. Iceland ignored the advice of the IMF, and instead invested in social protection. This investment was coupled with active measures to get people back into work. ‘Finally, the Icelandic people drew on strong reserves of social capital, and everyone really felt that they were united in the crisis. Although extrapolation to other countries should be undertaken with care, Iceland, by challenging the economic orthodoxy at every step of its response, has shown that an alternative to austerity exists’. [9] 

Secondly, the fiscal realities that frames available public financing for health systems and health workforce salaries, is shaped by issues as untaxed wealth, capital flight and wealth inequalities. Fewer than 100.00 people –that is 0,0001 % of the world’s population -  now control over 30% of the world’s financial wealth. Data from 139 mostly LMICs shows us that they had an aggregated debt of 4.1 trillion US$ at the end of 2010.  But once you take their foreign reserves and the offshore private holdings of their wealthiest citizens into account, the picture flips into reverse: these 139 countries have aggregate net debts of minus US$10.1-13.1 Trillion US$. So these countries are net creditors to the world, and in a big way. The problem here is that their assets are held by a small number of wealthy individuals, while their debts are shouldered by their ordinary people through their governments[10].

Regarding tax evasion; 23.400 “mailbox” companies are registered in the Netherlands, with its infamous tax heaven industry. It lead for instance to Portuguese and Spanish multinationals to avoid paying tax in their respective countries. As a result of the crises both Spain and Portugal bailed-out banks, and had to severely cut their public spending on health expenditures and health workforce salaries, as we have seen above. A logical conclusion follows, if we want to safeguard our health systems, we should challenge tax evasion and re-invest these financial resources in national social protection schemes including health.

I will not further elaborate on domestic and international migration of health workers from the South to the North, that has been partly the result of  fiscal policies restricting the absorption of health workers in national health systems. There is range of literature on brain drain in relation to health workforce migration, and has been dubbed a “perverse subsidy”. [11]  One author states in an overview paper that ”Global trade liberalization (via WTO “mode 4”)  has led to an international movement of health service providers. This can generate remittances, contribute to the exchange of knowledge among professionals, and provide countries of destination with otherwise unavailable skills. The permanent emigration of health workers may exacerbate health workers shortages in source countries, thus hampering adequate service delivery. Already fragile health systems are further weakened, while public resources invested in their training are lost”.[12]

Solutions for a stronger health workforce

The response by the WHO and the global community on these health workforce “scarcities and imbalances“ have been ambiguous. The Global Health Workforce Alliance (GHWA) has been initiated in 2006, and brings together a wide range of actors, that are looking for multiple-stakeholder solutions both at national and the international level. This has led to considerable attention and funding for training programs as to scale up the health workforce, to  improve national planning capacity and evidence , and programs on task-shifting and the integration of community health workers. The Kampala declaration an agenda for action, emerging from the first global forum on human resources for health in 2008, indicates 6 areas that require attention, including the points above but also managing the pressure of the international health workforce market and retaining an equitably distributed health workforce[13]. WHO has and is providing technical guidance on the retention of health workers to rural areas, as well as guidelines to scale-up the workforce. Donors like USAID, DFID and JICA have invested considerably in the training of community and professional health workers, in countries as diverse as Malawi, Bangladesh and Ethiopia. Most importantly, the WHO has brokered a Global Code of Practice on the international recruitment of health personnel that has been adopted at the World Health Assembly in 2010.[14] In this Code WHOs 194 member states  have agreed to address the global and ethical dimensions of health workforce migration. The code provides guidance to more fair and rights based approach to the recruitment of health workers. Three years after adoption of the voluntary code it has been mainly European countries that submitted a progress report to WHO and undertook (some) action. 

Although WHO and the GHWA call for political engagement and involvement of government leaders and Ministries of Finance in preparing health workforce policies; its approaches are mainly addressing technical capacities within the health sector.  So far limited capacity has been built by these organizations to have health workforce policies addressed in relation to national fiscal policies and larger macro-economic policy frameworks.  In general, public health capacity, for instance via health impact assessments, can be strengthened. This can provide evidence based responses to e.g. bilateral or regional Trade Agreements, liberalization of the labor markets, fiscal flexibility for public services, There might be a role for NGOs to be involved in future capacity sharing on this matter, and that can be built forward on current  involvement in health systems strengthening.

Some LMIC countries have recently developed capacity and an approach to develop strong public services. Brazil is a good example in this, and its workforce ratios have improved considerably over the 20 years. The Brazilian public sector has played a crucial role in promoting stability and setting up the conditions for economic and social development. Workforce policies are linked to expansion of the Unified Health System (Sistema Unico de Saúde - SUS). Due to national and state national health conferences, and via a strong HRH observatory, a momentum to build a comprehensive health system has maintained.[15] Thailand has also been able to strengthen its system. Via a multiple of health sector and socio-economic reforms that have led to a more balanced and well distributed and motivated workforce.[16] In Africa, countries like Malawi and Kenya have made some progress in expanding its workforce by implementing emergency programs that, via the use of donor-funding, by-passed fiscal caps and were able to increase its publicly employed health work with more than 20%.  The impact on the longer term remains to be seen, as much donor funding to the countries has stopped over the last years, and we have to observe how these governments invest in the health workforce on the long term.

Conclusion

The last 2 years or so, attention to the health workforce in the global health debate has reduced. This is probably because much attention goes to Universal Health Coverage and its financing mechanisms, also in relation to the post 2015 development framework. In Europe we have turned our attention to our own health service systems that are under severe pressure. Whether in Europe or in LMICs, the availability of a strong workforce remains a prerequisite for a strong universal and qualitative systems. We should keep our attention to health workforce in relation to UHC, as this might become otherwise the bottleneck to attain comprehensive health systems. And what will be the role of health workers in such a system? Will it be merely providing selective diagnosis and treatment, or will they have the autonomous space to address health of people and communities from an integrated and public health approach? The Alma Ata PHC concept envisages the latter, but even in more advanced health systems in Europe, there is more and more the tendency for health workers to work cost-effectively in a more results based financing matter. The orientation of this model to treating diseases rather than promoting health reduces the health worker to merely a production unit. We do not only need health workers, we require professionals in society working on health and wellbeing. The Finnish government provides good examples how this can be done.[17].  

Let me end with a quote by Rick Rowden: “While health advocates are right to criticize that “the IMF blocks health spending,” it is more comprehensive to say that “the IMF blocks the development of domestic industrialization; and without building domestic industries, jobs, and economic diversification over time, you can’t build a tax base for future increased expenditure; and without a growing tax base for future increased public expenditure, you can’t adequately finance a health budget”[18].  We must keep this in mind when building our future health workforce both in Europe and countries elsewhere.  

Dr. Remco van de Pas, Wemos foundation, the Netherlands
remco.van.de.pas@wemos.nl

Contribution to the Jubilee Conference "50 years Medicus Mundi:  Atención Primaria de Salud y Cooperación: ¿una utopía?". Barcelona, 7 June 2013

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[1] Ted Schrecker. Interrogating scarcity: how to think about ‘resource-scarce settings'. Health Policy Plan. 2012  published 16 August 2012. Available at: http://heapol.oxfordjournals.org/content/early/2012/08/16/heapol.czs071.full.pdf+html?etoc

[2] Fukuyama F. The end of history? 1989.The National Interest. Available at: http://www.wesjones.com/eoh.htm

[3]    WHO. World Health Report 2006. Working together for health. Chapter 1. Health workers a global profile. Available at: http://www.who.int/whr/2006/06_chap1_en.pdf

[4]    Lehmann U, Van Damme W, Barten F, Sanders D: Task shifting: the answer to the human resources crisis in Africa?Hum Resour Health 2009, 7:49. Available at: http://www.human-resources-health.com/content/pdf/1478-4491-7-49.pdf

[5]    Wibulpolprasert S, Pengpaiboon P: Integrated strategies to tackle the inequitable distribution of doctors in Thailand: four decades of experience. Human Resources for Health 2003, 1:12. Available at: http://www.human-resources-health.com/content/pdf/1478-4491-1-12.pdf

[6]    Klein N . The Shock doctrine (the rise of disaster capitalism). Knopf Canada. 2007. 

[7]    Center for Global Development. Does the IMF constrain health spending in poor countries?  Report of the working Group on IMF Programs and Health Spending. June 2007. Available at: http://www.cgdev.org/files/14103_file_IMF_report.pdf

[8]    Karanikolos et al, Financial crisis, austerity, and health in Europe. The Lancet - 13 April 2013 ( Vol. 381, Issue 9874, Pages 1323-1331). Available at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2960102-6/fulltext?_eventId=login

[9]    Ibid 8.

[10]  Henry, JS  The price of offschore revisited. NEW ESTIMATES FOR MISSING GLOBALPRIVATE WEALTH, INCOME, INEQUALITY, AND LOST TAXES. Tax Justice Network. July 2012. Available at: http://www.taxjustice.net/cms/upload/pdf/Price_of_Offshore_Revisited_26072012.pdf

[11]  Global Health Watch 1, An alternative world health report. The global health worker crises. 2005. Available at:     http://www.ghwatch.org/sites/www.ghwatch.org/files/B3.pdf

[12]  Missoni E. Understanding the impact of Global Trade Liberalization on health systems pursuing Universal Health Coverage. Value in Health. 2013. Volume 16, Issue 1, Pages S14-S18 

[13]  WHO & the Global Health Workforce Alliance. The Kampala Declaration and Agenda for Action. 2008. Available at:http://www.who.int/workforcealliance/Kampala%20Declaration%20and%20Agenda%20web%20file.%20FINAL.pdf

[14] WHO. The global code of Practice on the international recruitment of health personnel. Sixty-third World Health Assembly. WHA 63.13. May 2010. Available at: http://www.who.int/hrh/migration/code/code_en.pdf

[15]. Buchan J, Fronteira I, Dussault G,, Continuity and change in human resources policies for health: lessons from Brazil. Human Resources for Health 2011, 9:17. Available at: http://www.human-resources-health.com/content/9/1/17

[16] Ibid 5.

[17] Melkas T. Health in all policies as a priority in Finnish health policy: a case study on national health policy development. Scand J Public Health. 2013 Mar;41(11 Suppl):3-28. Available at : http://sjp.sagepub.com/content/41/11_suppl/3.long

[18] Rick Rowden. Why health advocates must get involved in development economics: the case of the International Monetary Fund. International Journal of Health Services, Volume 40, Number 1, Pages 183–187, 2010. Available at: http://people.ds.cam.ac.uk/ds450/details/rowden_IMFhealth.pdf