Implementation of policy and management interventions to improve health and care workforce capacity to address the COVID-19 pandemic response: a systematic review.

BACKGROUND: The COVID-19 pandemic highlighted pre-existing weaknesses in health and care systems and services and shortages of health and care workers (HCWs). As a result, policymakers needed to adopt measures to improve the health and care workforce (HCWF) capacity. This review aims to identify countries' range of policies and management interventions implemented to improve HCWs' capacity to address the COVID-19 pandemic response, synthesize their evidence on effectiveness, and identify gaps in the evidence. METHODS: The literature was searched in PubMed, Embase, Scopus, LILACS-BVS, WHO's COVID-19 Research Database and the ILO, OECD and HSRM websites for literature and documents published between January 2020 and March 2022. Eligibility criteria were HCWs as participants and policy and management interventions aiming to improve HCWF capacity to address the COVID-19 pandemic response. Risk of bias was assessed with Joanna Briggs Institute (JBI) Critical Appraisal Tools (CAT) and certainty of the evidence in presented outcomes with GRADE. RESULTS: The searches retrieved 3378 documents. A total of 69 were included, but only 8 presented outcomes of interventions implemented. Most of the selected documents described at least one intervention implemented by countries at the organizational environment level to increase the flexibility and capacity of the HCWF to respond to the pandemic, followed by interventions to attract and retain HCWs in safe and decent working environments. There was a lack of studies addressing social protection, human resources for health information systems, and regarding the role of community health workers and other community-based providers. Regarding the risk of bias, most of documents were rated as medium or high quality (JBI's CAT), while the evidence presented for the outcomes of interventions was classified as mostly low-certainty evidence (GRADE). CONCLUSIONS: Countries have implemented various interventions, some innovative, in response to the pandemic, and others had their processes started earlier and accelerated by the pandemic. The evidence regarding the impact and efficacy of the strategies used by countries during the pandemic still requires further research.

Design, delivery and effectiveness of health practitioner regulation systems: an integrative review.

BACKGROUND: Health practitioner regulation (HPR) systems are increasingly recognized as playing an important role in supporting health workforce availability, accessibility, quality, and sustainability, while promoting patient safety. This review aimed to identify evidence on the design, delivery and effectiveness of HPR to inform policy decisions. METHODS: We conducted an integrative analysis of literature published between 2010 and 2021. Fourteen databases were systematically searched, with data extracted and synthesized based on a modified Donabedian framework. FINDINGS: This large-scale review synthesized evidence from a range of academic (n = 410) and grey literature (n = 426) relevant to HPR. We identified key themes and findings for a series of HPR topics organized according to our structures-processes-outcomes conceptual framework. Governance reforms in HPR are shifting towards multi-profession regulators, enhanced accountability, and risk-based approaches; however, comparisons between HPR models were complicated by a lack of a standardized HPR typology. HPR can support government workforce strategies, despite persisting challenges in cross-border recognition of qualifications and portability of registration. Scope of practice reform adapted to modern health systems can improve access and quality. Alternatives to statutory registration for lower-risk health occupations can improve services and protect the public, while standardized evaluation frameworks can aid regulatory strengthening. Knowledge gaps remain around the outcomes and effectiveness of HPR processes, including continuing professional development models, national licensing examinations, accreditation of health practitioner education programs, mandatory reporting obligations, remediation programs, and statutory registration of traditional and complementary medicine practitioners. CONCLUSION: We identified key themes, issues, and evidence gaps valuable for governments, regulators, and health system leaders. We also identified evidence base limitations that warrant caution when interpreting and generalizing the results across jurisdictions and professions. Themes and findings reflect interests and concerns in high-income Anglophone countries where most literature originated. Most studies were descriptive, resulting in a low certainty of evidence. To inform regulatory design and reform, research funders and governments should prioritize evidence on regulatory outcomes, including innovative approaches we identified in our review. Additionally, a systematic approach is needed to track and evaluate the impact of regulatory interventions and innovations on achieving health workforce and health systems goals.

A novel approach to estimate the impact of health workforce investments on health outcomes through increased coverage of HIV, TB and malaria services.

BACKGROUND: Globally, HIV, TB and malaria account for an estimated three million deaths annually. The Global Fund partnered with the World Health Organization to assist countries with health workforce planning in these areas through the development of an integrated health workforce investment impact tool. Our study illustrates the development of a user-friendly tool (with two MS Excel calculator subcomponents) that computes associations between human resources for health (HRH) investment inputs and reduced morbidity and mortality from HIV, TB, and malaria via increased coverage of effective treatment services. METHODS: We retrieved from the peer-reviewed literature quantitative estimates of the relation among HRH inputs and HRH employment and productivity. We converted these values to additional full-time-equivalent doctors, nurses and midwives (DNMs). We used log-linear regression to estimate the relation between DNMs and treatment service coverage outcomes for HIV, TB, and malaria. We then retrieved treatment effectiveness parameters from the literature to calculate lives saved due to expanded treatment coverage for HIV, TB, and malaria. After integrating these estimates into the tool, we piloted it in four countries. RESULTS: In most countries with a considerable burden of HIV, TB, and malaria, the health workforce investments include a mix of pre-service education, full remuneration of new hires, various forms of incentives and in-service training. These investments were associated with elevated HIV, TB and malaria treatment service coverage and additional lives saved. The country case studies we developed in addition, indicate the feasibility and utility of the tool for a variety of international and local actors interested in HRH planning. CONCLUSIONS: The modelled estimates developed for illustrative purposes and tested through country case studies suggest that HRH investments result in lives saved across HIV, TB, and malaria. Furthermore, findings show that attainment of high targets of specific treatment coverage indicators would require a substantially greater health workforce than what is currently available in most LMICs. The open access tool can assist with future HRH planning efforts, particularly in LMICs.

The global health and care worker compact: evidence base and policy considerations.

BACKGROUND: During the COVID-19 pandemic, and recognising the sacrifice of health and care workers alongside discrimination, violence, poor working conditions and other violations of their rights, health and safety, in 2021 the World Health Assembly requested WHO to develop a global health and care worker compact, building on existing normative documentation, to provide guidance to 'protect health and care workers and safeguard their rights'. METHODS: A review of existing international law and other normative documents was conducted. We manually searched five main sets of international instruments: (1) International Labour Organization conventions and recommendations; (2) WHO documents; (3) United Nations (UN) human rights treaties and related documents; (4) UN Security Council and General Assembly resolutions and (5) the Geneva Conventions and Additional Protocols. We included only legal or other normative documents with a global or regional focus directly addressing or relevant to health and care workers or workers overall. RESULTS: More than 70 documents met our search criteria. Collectively, they fell into four domains, within which we identified 10 distinct areas: (1) preventing harm, encompassing (A) occupational hazards, (B) violence and harassment and (C) attacks in situations of fragility, conflict and violence; (2) inclusivity, encompassing (A) non-discrimination and equality; (3) providing support, encompassing (A) fair and equitable remuneration, (B) social protection and (C) enabling work environments and (4) safeguarding rights, encompassing (A) freedom of association and collective bargaining and (B) whistle-blower protections and freedom from retaliation. DISCUSSION: A robust legal and policy framework exists for supporting health and care workers and safeguarding their rights. Specific human rights, the right to health overall, and other binding and non-binding legal documents provide firm grounding for the compact.However, these existing commitments are not being fully met. Implementing the compact will require more effective governance mechanisms and new policies, in partnership with health and care workers themselves.

The roles and involvement of global health partners in the health workforce: an exploratory analysis.

Development partners and global health initiatives are important actors in financing health systems in many countries. Despite the importance of the health workforce to the attainment of global health targets, the contribution of global health initiatives to health workforce strengthening is unclear. A 2020 milestone in the Global Strategy on Human Resources for Health is that "all bilateral and multilateral agencies have participated in efforts to strengthen health workforce assessments and information exchange in countries." This milestone exists to encourage strategic investments in the health workforce that are evidence-based and incorporate a health labour market approach as an indication of policy comprehensiveness. To assess progress against this milestone, we reviewed the activities of 23 organizations (11 multilaterals and 12 bilaterals) which provide financial and technical assistance to countries for human resources for health, by mapping grey and peer-reviewed literature published between 2016 and 2021. The Global Strategy states that health workforce assessment involves a "deliberate strategy and accountability mechanisms on how specific programming contributes to health workforce capacity-building efforts" and avoids health labour market distortions. Health workforce investments are widely recognized as essential for the achievement of global health goals, and some partners identify health workforce as a key strategic focus in their policy and strategy documents. However, most do not identify it as a key focus, and few have a published specific policy or strategy to guide health workforce investments. Several partners include optional health workforce indicators in their monitoring and evaluation processes and/or require an impact assessment for issues such as the environment and gender equality. Very few, however, have embedded efforts in their governance mechanisms to strengthen health workforce assessments. On the other hand, most have participated in health workforce information exchange activities, including strengthening information systems and health labour market analyses. Although there is evidence of participation in efforts to strengthen health workforce assessments and (especially) information exchange, the achievement of this milestone of the Global Strategy requires more structured policies for the monitoring and evaluation of health workforce investments to optimize the value of these investments and contribute towards global and national health goals.

Health worker education during the COVID-19 pandemic: global disruption, responses and lessons for the future-a systematic review and meta-analysis.

BACKGROUND: This systematic review and meta-analysis identified early evidence quantifying the disruption to the education of health workers by the COVID-19 pandemic, ensuing policy responses and their outcomes. METHODS: Following a pre-registered protocol and PRISMA/AMSTAR-2 guidelines, we systematically screened MEDLINE, EMBASE, Web of Science, CENTRAL, clinicaltrials.gov and Google Scholar from January 2020 to July 2022. We pooled proportion estimates via random-effects meta-analyses and explored subgroup differences by gender, occupational group, training stage, WHO regions/continents, and study end-year. We assessed risk of bias (Newcastle-Ottawa scale for observational studies, RοB2 for randomized controlled trials [RCT]) and rated evidence certainty using GRADE. RESULTS: Of the 171 489 publications screened, 2 249 were eligible, incorporating 2 212 observational studies and 37 RCTs, representing feedback from 1 109 818 learners and 22 204 faculty. The sample mostly consisted of undergraduates, medical doctors, and studies from institutions in Asia. Perceived training disruption was estimated at 71.1% (95% confidence interval 67.9-74.2) and learner redeployment at 29.2% (25.3-33.2). About one in three learners screened positive for anxiety (32.3%, 28.5-36.2), depression (32.0%, 27.9-36.2), burnout (38.8%, 33.4-44.3) or insomnia (30.9%, 20.8-41.9). Policy responses included shifting to online learning, innovations in assessment, COVID-19-specific courses, volunteerism, and measures for learner safety. For outcomes of policy responses, most of the literature related to perceptions and preferences. More than two-thirds of learners (75.9%, 74.2-77.7) were satisfied with online learning (postgraduates more than undergraduates), while faculty satisfaction rate was slightly lower (71.8%, 66.7-76.7). Learners preferred an in-person component: blended learning 56.0% (51.2-60.7), face-to-face 48.8% (45.4-52.1), and online-only 32.0% (29.3-34.8). They supported continuation of the virtual format as part of a blended system (68.1%, 64.6-71.5). Subgroup differences provided valuable insights despite not resolving the considerable heterogeneity. All outcomes were assessed as very-low-certainty evidence. CONCLUSION: The COVID-19 pandemic has severely disrupted health worker education, inflicting a substantial mental health burden on learners. Its impacts on career choices, volunteerism, pedagogical approaches and mental health of learners have implications for educational design, measures to protect and support learners, faculty and health workers, and workforce planning. Online learning may achieve learner satisfaction as part of a short-term solution or integrated into a blended model in the post-pandemic future.

Health workforce governance for compassionate and respectful care: a framework for research, policy and practice.

The progressive realisation of universal health coverage requires that health services are not only available and accessible, but also that they are rendered to the population in an acceptable, compassionate and respectful manner to deliver quality of care. Health workers' competencies play a central role in the provision of compassionate and respectful care (CRC); but health workers' behaviour is also influenced by the policy and governance environment in which they operate. The identification of relevant policy levers to enhance CRC therefore calls for actions that enable health workers to optimise their roles and fulfil their responsibilities.This paper aims at exploring the health workforce policy and management levers to enable CRC. Through an overview of selected country experiences, concrete examples are provided to illustrate the range of available policy options. Relevant interventions may span the individual, organisational, or system-wide level. Some policies are specific to CRC and may include, among others, the inclusion of relevant competencies in preservice and in-service education, supportive supervision and accountability mechanisms. Other relevant actions depend on a broader workforce governance approach, including policies that target health workforce availability, distribution and working conditions, or wider system -level factors, including regulatory and financing aspects.The selection of the appropriate system-wide and CRC-specific interventions should be tailored to the national and operational context in relation to its policy objectives and feasibility and affordability considerations. The identification of performance metrics and the collation and analysis of required data are necessary to monitor effectiveness of the interventions adopted.

Correction to: Are the Global Strategic Directions for Strengthening Nursing and Midwifery 2016-2020 being implemented in countries? Findings from a cross-sectional analysis.

An amendment to this paper has been published and can be accessed via the original article.

Developing the health workforce for universal health coverage.

Optimizing the management of the health workforce is necessary for the progressive realization of universal health coverage. Here we discuss the six main action fields in health workforce management as identified by the Human Resources for Health Action Framework: leadership; finance; policy; education; partnership; and human resources management systems. We also identify and describe examples of effective practices in the development of the health workforce, highlighting the breadth of issues that policy-makers and planners should consider. Achieving success in these action fields is not possible by pursuing them in isolation. Rather, they are interlinked functions that depend on a strong capacity for effective stewardship of health workforce policy. This stewardship capacity can be best understood as a pyramid of tools and factors that encompass the individual, organizational, institutional and health system levels, with each level depending on capacity at the level below and enabling actions at the level above. We focus on action fields covered by the organizational or system-wide levels that relate to health workforce development. We consider that an analysis of the policy and governance environment and of mechanisms for health workforce policy development and implementation is required, and should guide the identification of the most relevant and appropriate levels and interventions to strengthen the capacity of health workforce stewardship and leadership. Although these action fields are relevant in all countries, there are no best practices that can simply be replicated across countries and each country must design its own responses to the challenges raised by these fields.

Il est nécessaire d'optimiser la gestion du personnel de santé pour parvenir progressivement à la couverture sanitaire universelle. Dans cet article, nous nous intéressons aux six grands domaines d'action en matière de gestion du personnel de santé qui sont définis dans le Cadre d'action concernant les ressources humaines pour la santé: leadership; finances; politiques; éducation; partenariats; et systèmes de gestion des ressources humaines. Nous décrivons également des exemples de pratiques efficaces pour renforcer le personnel de santé, en mettant en avant l'étendue des questions que les responsables politiques et les planificateurs devraient prendre en compte. Il n'est pas possible de réussir dans ces domaines d'action en les abordant de manière séparée. Ce sont des fonctions étroitement liées qui dépendent d'une forte capacité à gérer efficacement les politiques relatives au personnel de santé. Cette capacité de gestion peut être mieux comprise sous la forme d'une pyramide d'outils et de facteurs englobant les niveaux des individus, des organisations, des institutions et des systèmes de santé, dans laquelle chaque niveau dépend de la capacité du niveau inférieur et permet d'agir au niveau supérieur. Nous nous intéressons ici aux domaines d'action qui correspondent aux niveaux des organisations ou des systèmes et qui concernent le renforcement du personnel de santé. Selon nous, il est indispensable d'analyser le cadre stratégique et les structures de gouvernance, ainsi que les mécanismes d'élaboration et de mise en œuvre des politiques relatives au personnel de santé. Cette analyse devrait permettre de déterminer les niveaux et les interventions les plus appropriés pour renforcer la capacité de gestion et de direction du personnel de santé. Bien que ces domaines d'action concernent tous les pays, aucune meilleure pratique ne peut être simplement reproduite dans tous les pays. Chaque pays doit trouver ses propres réponses aux questions soulevées par ces domaines.

La optimización de la gestión de la fuerza laboral sanitaria es necesaria para la realización progresiva de la cobertura sanitaria universal. La optimización de la gestión de la fuerza laboral sanitaria es necesaria para la realización progresiva de la cobertura sanitaria universal. En este documento se examinan los seis campos de acción principales de la gestión de la fuerza laboral sanitaria identificados en el Marco de Acción de Recursos Humanos para la Salud: liderazgo, finanzas, políticas, educación, asociaciones y sistemas de gestión de los recursos humanos. También se identifican y describen ejemplos de prácticas efectivas en el desarrollo de la fuerza laboral sanitaria, destacando la amplitud de los temas que los responsables de formular políticas y los planificadores deben considerar. No es posible alcanzar el éxito en estos campos de acción si se persiguen de forma aislada. Más bien, se trata de funciones interrelacionadas que dependen de una fuerte capacidad de gestión eficaz de la política de la fuerza laboral sanitaria. Esta capacidad de gestión puede entenderse mejor como una pirámide de herramientas y factores que abarcan los niveles individual, organizativo, institucional y del sistema de salud, en la que cada nivel depende de la capacidad en el nivel inferior y de las medidas de habilitación en el nivel superior. Se hace énfasis en los campos de acción cubiertos por los niveles de la organización o de todo el sistema que se relacionan con el desarrollo de la fuerza laboral sanitaria. En este contexto, es necesario realizar un análisis del entorno normativo y de gobernanza y de los mecanismos para el desarrollo y la implementación de las políticas de la fuerza laboral sanitaria, y debe guiar la identificación de los niveles e intervenciones más pertinentes y apropiados para fortalecer la capacidad de gestión y liderazgo de la fuerza laboral sanitaria. Aunque estos campos de acción son relevantes en todos los países, no hay mejores prácticas que puedan ser simplemente replicadas a través de los países y cada país debe diseñar sus propias respuestas a los desafíos planteados por estos campos.

Are the Global Strategic Directions for Strengthening Nursing and Midwifery 2016-2020 being implemented in countries? Findings from a cross-sectional analysis.

BACKGROUND: Nurses and midwives are the largest component of the health workforce in many countries. The World Health Organization (WHO) together with its partners facilitates the joint development of strategic policy guidance for countries to support the optimization of their nursing and midwifery workforce. The Global Strategic Directions for Strengthening Nursing and Midwifery 2016-2020 (SDNM) is a global policy guidance tool that provides a framework for Member States, the WHO and its partners to adapt, develop, implement and evaluate nursing and midwifery policy interventions in Member States. As part of the broader monitoring and accountability functions of the WHO, assessing the progress of the SDNM implementation at a country level is key to ensuring that countries stay on track towards achieving universal health coverage (UHC) and the sustainable development goals (SDGs). METHODS: This is a cross-sectional mixed methods study involving the analysis of quantitative and qualitative data on the implementation of country-level interventions in the SDNM. Data was provided by government chief nursing and midwifery officers or their representatives using an online self-reported questionnaire. The quantitative data was assessed using a three-level scale and descriptive statistics while qualitative comments were analysed and presented narratively. RESULTS: Thirty-five countries completed the survey. Summing up the implementation frequency of interventions across all thematic areas, 19% of responses were in the category of "completed"; 55% were reportedly "in progress" and 26% indicated a status of "not started". Findings reveal a stronger level of implementation for areas of nursing and midwifery development related to enhancing regulation and education, creating stronger roles for professional associations and policy strengthening. Leadership and interprofessional collaboration are intervention areas that were less implemented. CONCLUSION: Monitoring and accountability of countries' commitments towards implementing nursing and midwifery interventions, as outlined in the SDNM, contributes to strengthening the evidence base for policy reforms in countries. This stock-taking can inform policy- and decision-makers' deliberations on strengthening the contributions of nurses and midwives to achieving UHC and the SDGs.

Analysing public sector institutional capacity for health workforce governance in the South-East Asia region of WHO.

BACKGROUND: In order to analyse the institutional capacity for health workforce policy development and implementation in countries in the South-East Asia region, the WHO facilitated a cross-sectional analysis of functions performed, structure, personnel, management and information systems of human resources for health (HRH) units in Ministries of Health. CASE PRESENTATION: A self-assessment survey on the characteristics and roles of HRH units was administered to relevant Government officials; the responses were validated through face-to-face workshops and by the WHO staff. Findings were tabulated to produce frequency distributions of the variables examined, and qualitative elements categorized according to a framework for capacity building in the health sector. Ten countries out of the 11 in the region responded to the survey. Seven out of 10 reported having an HRH unit, though their scope, roles, capacity and size displayed considerable variability. Some functions (such as planning and health workforce data management) were reportedly carried out in all countries, while others (inter-sectoral coordination, research, labour relations) were only performed in few. DISCUSSION AND CONCLUSIONS: The strengthening of the HRH governance capacity in countries should follow a logical hierarchy, identifying first and foremost the essential functions that the public sector is expected to perform to optimize HRH governance. The definition of expected roles and functions will in turn allow identifying the upstream system-wide factors and the downstream capacity requirements for the strengthening of the HRH units. The focus should ultimately be on ensuring that all the key strategic functions are performed to quality standards, irrespective of institutional arrangements.

Stakeholders' perceptions of policy options to support the integration of community health workers in health systems.

BACKGROUND: Community health workers (CHWs) are an important component of the health workforce in many countries. The World Health Organization (WHO) has developed a guideline to support the integration of CHWs into health systems. This study assesses stakeholders' valuation of outcomes of interest, acceptability and feasibility of policy options considered for the CHW guideline development. METHODS: A cross-sectional mixed methods (quantitative and qualitative) study targeting stakeholders involved directly or indirectly in country implementation of CHW programmes was conducted in 2017. Data was collected from 96 stakeholders from five WHO regions using an online questionnaire. A Likert scale (1 to 9) was used to grade participants' assessments of the outcomes of interest, and the acceptability and feasibility of policy options were considered. RESULTS: All outcomes of interest were considered by at least 90% of participants as 'important' or 'critical'. Most critical outcomes were 'improved quality of CHW health services' and 'increased health service coverage' (91.5% and 86.2% participants judging them as 'critical' respectively). Out of 40 policy options, 35 were considered as 'definitely acceptable' and 36 'definitely feasible' by most participants. The least acceptable option (37% of participants rating 'definitely not acceptable') was the selection of candidates based on age. The least feasible option (29% of participants rating 'definitely not feasible') was the selection of CHWs with a minimum of secondary education. CONCLUSION: Outcomes of interest and policy options proposed were rated highly by most stakeholders. This finding helps to reinforce their usefulness in meeting the expectations of the CHW guideline end-users to properly integrate CHWs into health systems.

Health policy and system support to optimise community health worker programmes: an abridged WHO guideline.

Optimising community health worker (CHW) programmes requires evidence-based policies on their education, deployment, and management. This guideline aims to inform efforts by planners, policy makers, and managers to improve CHW programmes as part of an integrated approach to strengthen primary health care and health systems. The development of this guideline followed the standard WHO approach to developing global guidelines. We conducted one overview of reviews, 15 systematic reviews (each one on a specific policy question), and a survey of stakeholders' views on the acceptability and feasibility of the interventions under consideration. We assessed the quality of systematic reviews using the AMSTAR tool, and the certainty of the evidence using the GRADE methodology. The overview of reviews identified 122 eligible articles and the systematic reviews identified 137 eligible primary studies. The stakeholder perception survey obtained inputs from 96 respondents. Recommendations were developed in the areas of CHW selection, preservice education, certification, supervision, remuneration and career advancement, planning, community embeddedness, and health system support. These are the first evidence-based global guidelines for health policy and system support to optimise community health worker programmes. Key considerations for implementation include the need to define the role of CHWs in relation to other health workers and plan for the health workforce as a whole rather than by specific occupational groups; appropriately integrate CHW programmes into the general health system and existing community systems; and ensure internal coherence and consistency across different policies and programmes affecting CHWs.

What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers.

OBJECTIVE: To synthesize current understanding of how community-based health worker (CHW) programs can best be designed and operated in health systems. METHODS: We searched 11 databases for review articles published between 1 January 2005 and 15 June 2017. Review articles on CHWs, defined as non-professional paid or volunteer health workers based in communities, with less than 2 years of training, were included. We assessed the methodological quality of the reviews according to AMSTAR criteria, and we report our findings based on PRISMA standards. FINDINGS: We identified 122 reviews (75 systematic reviews, of which 34 are meta-analyses, and 47 non-systematic reviews). Eighty-three of the included reviews were from low- and middle-income countries, 29 were from high-income countries, and 10 were global. CHW programs included in these reviews are diverse in interventions provided, selection and training of CHWs, supervision, remuneration, and integration into the health system. Features that enable positive CHW program outcomes include community embeddedness (whereby community members have a sense of ownership of the program and positive relationships with the CHW), supportive supervision, continuous education, and adequate logistical support and supplies. Effective integration of CHW programs into health systems can bolster program sustainability and credibility, clarify CHW roles, and foster collaboration between CHWs and higher-level health system actors. We found gaps in the review evidence, including on the rights and needs of CHWs, on effective approaches to training and supervision, on CHWs as community change agents, and on the influence of health system decentralization, social accountability, and governance. CONCLUSION: Evidence concerning CHW program effectiveness can help policymakers identify a range of options to consider. However, this evidence needs to be contextualized and adapted in different contexts to inform policy and practice. Advancing the evidence base with context-specific elements will be vital to helping these programs achieve their full potential.

Forecasting imbalances in the global health labor market and devising policy responses.

BACKGROUND: The High-Level Commission on Health Employment and Economic Growth released its report to the United Nations Secretary-General in September 2016. It makes important recommendations that are based on estimates of over 40 million new health sector jobs by 2030 in mostly high- and middle-income countries and a needs-based shortage of 18 million, mostly in low- and middle-income countries. This paper shows how these key findings were developed, the global policy dilemmas they raise, and relevant policy solutions. METHODS: Regression analysis is used to produce estimates of health worker need, demand, and supply. Projections of health worker need, demand, and supply in 2030 are made under the assumption that historical trends continue into the future. RESULTS: To deliver essential health services required for the universal health coverage target of the Sustainable Development Goal 3, there will be a need for almost 45 million health workers in 2013 which is projected to reach almost 53 million in 2030 (across 165 countries). This results in a needs-based shortage of almost 17 million in 2013. The demand-based results suggest a projected demand of 80 million health workers by 2030. CONCLUSIONS: Demand-based analysis shows that high- and middle-income countries will have the economic capacity to employ tens of millions additional health workers, but they could face shortages due to supply not keeping up with demand. By contrast, low-income countries will face both low demand for and supply of health workers. This means that even if countries are able to produce additional workers to meet the need threshold, they may not be able to employ and retain these workers without considerably higher economic growth, especially in the health sector.

Tracing the policy implementation of commitments made by national governments and other entities at the Third Global Forum on Human Resources for Health.

We conducted a follow-up analysis of the implementation of the Human Resources for Health (HRH) commitments made by country governments and other actors at the Third Global Forum on HRH in 2013. Since then member states of the WHO endorsed Universal Health Coverage as the main policy objective whereby health systems strengthening, including reinforcement of the health workforce, can contribute to several Sustainable Development Goals. Now is the right time to trace the implementation of these commitments and to assess their contribution to broader global health objectives. The baseline data for this policy tracing study consist of the categorisation and analysis of the HRH commitments conducted in 2014. This analysis was complemented in application of the health policy triangle as its main analytical framework. An online survey and a guideline for semistructured interviews were developed to collect data. Information on the implementation of the commitments is available in 49 countries (86%). The need for multi-actor approaches for HRH policy development is universally recognised. A suitable political window and socioeconomic situation emerge as crucial factors for sustainable HRH development. However, complex crises in different parts of the world have diverted attention from investment in HRH development. The analysis indicates that investment in the health workforce and corresponding policy development relies on political leadership, coherent government strategies, institutional capacity and intersectoral governance mechanisms. The institutional capacity to shoulder such complex tasks varies widely across countries. For several countries, the commitment process provided an opportunity to invest in, develop and reform the health workforce. Nevertheless, the quality of HRH monitoring mechanisms requires more attention. In conclusion, HRH challenges, their different pathways and the intersectorality of the required responses are a concern for all the countries analysed. There is hence a need for national governments and stakeholders across the globe to share responsibilities and invest in this vital issue in a co-ordinated manner.

Assessing the health workforce implications of health policy and programming: how a review of grey literature informed the development of a new impact assessment tool.

BACKGROUND: In their adoption of WHA resolution 69.19, World Health Organization Member States requested all bilateral and multilateral initiatives to conduct impact assessments of their funding to human resources for health. The High-Level Commission for Health Employment and Economic Growth similarly proposed that official development assistance for health, education, employment and gender are best aligned to creating decent jobs in the health and social workforce. No standard tools exist for assessing the impact of global health initiatives on the health workforce, but tools exist from other fields. The objectives of this paper are to describe how a review of grey literature informed the development of a draft health workforce impact assessment tool and to introduce the tool. METHOD: A search of grey literature yielded 72 examples of impact assessment tools and guidance from a wide variety of fields including gender, health and human rights. These examples were reviewed, and information relevant to the development of a health workforce impact assessment was extracted from them using an inductive process. RESULTS: A number of good practice principles were identified from the review. These informed the development of a draft health workforce impact assessment tool, based on an established health labour market framework. The tool is designed to be applied before implementation. It consists of a relatively short and focused screening module to be applied to all relevant initiatives, followed by a more in-depth assessment to be applied only to initiatives for which the screening module indicates that significant implications for HRH are anticipated. It thus aims to strike a balance between maximising rigour and minimising administrative burden. CONCLUSION: The application of the new tool will help to ensure that health workforce implications are incorporated into global health decision-making processes from the outset and to enhance positive HRH impacts and avoid, minimise or offset negative impacts.

Health workforce metrics pre- and post-2015: a stimulus to public policy and planning.

BACKGROUND: Evidence-based health workforce policies are essential to ensure the provision of high-quality health services and to support the attainment of universal health coverage (UHC). This paper describes the main characteristics of available health workforce data for 74 of the 75 countries identified under the 'Countdown to 2015' initiative as accounting for more than 95% of the world's maternal, newborn and child deaths. It also discusses best practices in the development of health workforce metrics post-2015. METHODS: Using available health workforce data from the Global Health Workforce Statistics database from the Global Health Observatory, we generated descriptive statistics to explore the current status, recent trends in the number of skilled health professionals (SHPs: physicians, nurses, midwives) per 10 000 population, and future requirements to achieve adequate levels of health care in the 74 countries. A rapid literature review was conducted to obtain an overview of the types of methods and the types of data sources used in human resources for health (HRH) studies. RESULTS: There are large intercountry and interregional differences in the density of SHPs to progress towards UHC in Countdown countries: a median of 10.2 per 10 000 population with range 1.6 to 142 per 10 000. Substantial efforts have been made in some countries to increase the availability of SHPs as shown by a positive average exponential growth rate (AEGR) in SHPs in 51% of Countdown countries for which there are data. Many of these countries will require large investments to achieve levels of workforce availability commensurate with UHC and the health-related sustainable development goals (SDGs). The availability, quality and comparability of global health workforce metrics remain limited. Most published workforce studies are descriptive, but more sophisticated needs-based workforce planning methods are being developed. CONCLUSIONS: There is a need for high-quality, comprehensive, interoperable sources of HRH data to support all policies towards UHC and the health-related SDGs. The recent WHO-led initiative of supporting countries in the development of National Health Workforce Accounts is a very promising move towards purposive health workforce metrics post-2015. Such data will allow more countries to apply the latest methods for health workforce planning.