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.

The transition of human resources for health information systems from the MDGs into the SDGs and the post-pandemic era: reviewing the evidence from 2000 to 2022.

BACKGROUND: This review paper offers a policy-tracing trend analysis of national experiences among low- and middle-income countries in strengthening human resources for health information systems (HRHIS). This paper draws on evidence from the last two decades and applies a modified Bardach's policy analysis framework. A timely review of the evidence on HRHIS and underlying data systems is needed now more than ever, given the halfway mark of the Global Strategy on Human Resources for Health: Workforce 2030 and the protracted COVID-19 pandemic and other global health emergencies, over and above the increasing need for health and care workers to provide essential health services. MAIN TEXT: Considering World Health Assembly resolutions and HRH-related global developments between 2000 and 2022, we targeted peer-reviewed and gray literature covering the inception, impact, bottlenecks, and gaps of HRHIS. We also considered results from a Bill and Melinda Gates Foundation-funded project that assessed HRH data systems in 21 countries and the use of HRH data and information for policy, planning, and management. Aligned with the National Health Workforce Accounts (NHWA), we identify priority themes related to digital priorities for HRHIS and governance/leadership and present case studies of five countries that pursued different pathways to successfully develop their HRHIS. Over the last two decades, considerable progress has been achieved through a scaled-up implementation of HRHIS combined with the skills needed to analyze and use data, sustain systems functionality, and make systematic improvements over time. Global health development aid investments and technical innovations have led to advancements in HRHIS, district health information software (DHIS2), and partner collaborations during the HIV/AIDS, Ebola, and COVID-19 crises. Although the progressive implementation of NHWA continues to steer country-level efforts through standardized indicators and regular reporting, traditional challenges remain, such as data systems fragmentation, lack of interoperability between systems, and underutilization of reported data. Encouragingly, some countries demonstrate strong governance and leadership capacities and others strong HRHIS digital capacities. Both HRH and health service data are needed to inform on-demand decisions during times of emergencies and pandemics as well as during routine essential health services delivery. Evidence-based examples from distinctive countries demonstrate that reliable HRHIS is achievable for better planning and management of the health and care workforce.

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 inequity in COVID-19 vaccination coverage among health and care workers.

BACKGROUND: Health and care workers (HCWs) are at the forefront of COVID-19 response, at high risk of infection, and as a result they are a priority group for COVID-19 vaccination. This paper presents the global patterns in COVID-19 vaccination coverage among HCWs in 2021, how HCWs were prioritized, and identifies factors associated with the early vaccination coverage. METHODS: Using monthly data reported to the World Health Organization, the percentages of partially and fully vaccinated HCWs were computed. The rates of vaccination of HCWs for the first and second half of 2021 were compared in a stratified analysis using several factors. A multivariate analysis was used to investigate the independent associations of these factors with the percentage of HCWs fully vaccinated. RESULTS: Based on data from 139 Member States, as of end of 2021, 82% HCWs were reported as fully vaccinated with important variations by income groups: 33% for low income countries, 83% for lower-middle income countries, 79% for upper-middle income countries and 88% for high income countries. Overall 76% of countries did not achieve 70% vaccination coverage of their HCWs in the first half of 2021, and 38% of countries by end of 2021. Compared with the general population, the rate of HCWs full vaccination was 3.5 times higher, in particular for low income countries (RR = 5.9). Stratified analysis showed that beyond income group, the availability of vaccine doses was a critical factor of HCWs vaccination coverage with medians of 59.1% and 88.6% coverage in the first and second half of 2021, respectively for countries with enough doses to cover 70% of their population, compared with 0.8% and 47.5% coverage, respectively for countries with doses to cover 40% of their population. The multivariate analysis confirmed this observation with a 35.9% overall difference (95%CI 15.1%; 56.9%) between these two groups. CONCLUSION: Despite being considered a priority group, more than a third of countries did not achieve 70% vaccination coverage of their HCWs at the end of 2021. Large inequities were observed with low income countries lagging behind. Additional efforts should be dedicated to ensure full protection of HCWs through vaccination.

Inequal distribution of nursing personnel: a subnational analysis of the distribution of nurses across 58 countries.

BACKGROUND: Nursing personnel are critical for enabling access to health service in primary health care. However, the State of the World's Nursing 2020 report showed important inequalities in nurse availability between countries. METHODS: The purpose of this study/analysis was to describe the differences in nurse-to-population density in 58 countries from six regional areas and the relationship between differences in access to nurses and other indicators of health equity. RESULTS: All countries and income groups showed subnational inequalities in the distribution of nursing personnel with Gini coefficients ranging from 1 to 39. The latter indicated situation such as 13% of the population having access to 45% of nurses in a country. The average max-to-min ratio was on average of 11-fold. In our sample, the African region had the highest level of subnational inequalities with the average Gini coefficient of 19.6. The European Region had the lowest level of within-country inequalities with the average Gini coefficient being 5.6. A multivariate analysis showed a clustering of countries in three groups: (1) high Gini coefficients comprised mainly African countries; (2) moderate Gini coefficients comprised mainly South-East Asian, Central and South American countries; (3) low Gini coefficients comprised mainly Western countries, Japan, and Korea. The analysis also showed that inequality in distribution of nurses was correlated with other indices of health and inequality such as the Human Development Index, maternal mortality, and life expectancy. CONCLUSIONS: This study showed that there is a high level of geographic inequality in the distribution of nurses at subnational level. Inequalities in nursing distribution are multifactorial, to improve access to nurses, policies should be bundled, tailored to the local context and tackle the various root causes for inequalities.

Costing commodity and human resource needs for integrated community case management in thie differing community health strategies of Ethiopia, Kenya and Zambia.

BACKGROUND: To ensure correct and appropriate funding is available, there is a need to estimate resource needs for improved planning and implementation of integrated Community Case Management (iCCM). OBJECTIVE: To compare and estimate costs for commodity and human resource needs for iCCM, based on treatment coverage rates, bottlenecks and national targets in Ethiopia, Kenya and Zambia from 2014 to 2016. METHODS: Resource needs were estimated using Ministry of Health (MoH) targets fronm 2014 to 2016 for implementation of case management of pneumonia, diarrhea and malaria through iCCM based on epidemiological, demographic, economic, intervention coverage and other health system parameters. Bottleneck analysis adjusted cost estimates against system barriers. Ethiopia, Kenya and Zambia were chosen to compare differences in iCCM costs in different programmatic implementation landscapes. RESULTS: Coverage treatment rates through iCCM are lowest in Ethiopia, followed by Kenya and Zambia, but Ethiopia had the greatest increases between 2009 and 2012. Deployment of health extension workers (HEWs) in Ethiopia is more advanced compared to Kenya and Zambia, which have fewer equivalent cadres (called commu- nity health workers (CHWs)) covering a smaller proportion of the population. Between 2014 and 2016, the propor- tion of treatments through iCCM compared to health centres are set to increase from 30% to 81% in Ethiopia, 1% to 18% in Kenya and 3% to 22% in Zambia. The total estimated cost of iCCM for these three years are USD 75,531,376 for Ethiopia, USD 19,839,780 for Kenya and USD 33,667,742 for Zambia. Projected per capita expen- diture for 2016 is USD 0.28 for Ethiopia, USD 0.20 in Kenya and USD 0.98 in Zambia. Commodity costs for pneumonia and diarrhea were a small fraction of the total iCCM budget for all three countries (less than 3%), while around 80% of the costs related to human resources. CONCLUSION: Analysis of coverage, demography and epidemiology data improves estimates of fimding requirements for iCCM. Bottleneck analysis adjusts cost estimates by including system barriers, thus reflecting a more accurate estimate of potential resource utilization. Adding pneumonia and diarrhea interventions to existing large scale community-based malaria case management programs is likely to require relatively small and nationally affordable investments. iCCM can be implemented for USD 0.09 to 0.98 per capita per annum, depending on the stage of scale-up and targets set by the MoH.

The global health workforce stock and distribution in 2020 and 2030: a threat to equity and 'universal' health coverage?

OBJECTIVE: The 2016 Global Strategy on Human Resources for Health: Workforce 2030 projected a global shortage of 18 million health workers by 2030. This article provides an assessment of the health workforce stock in 2020 and presents a revised estimate of the projected shortage by 2030. METHODS: Latest data reported through WHO's National Health Workforce Accounts (NHWA) were extracted to assess health workforce stock for 2020. Using a stock and flow model, projections were computed for the year 2030. The global health workforce shortage estimation was revised. RESULTS: In 2020, the global workforce stock was 29.1 million nurses, 12.7 million medical doctors, 3.7 million pharmacists, 2.5 million dentists, 2.2 million midwives and 14.9 million additional occupations, tallying to 65.1 million health workers. It was not equitably distributed with a 6.5-fold difference in density between high-income and low-income countries. The projected health workforce size by 2030 is 84 million health workers. This represents an average growth of 29% from 2020 to 2030 which is faster than the population growth rate (9.7%). This reassessment presents a revised global health workforce shortage of 15 million health workers in 2020 decreasing to 10 million health workers by 2030 (a 33% decrease globally). WHO African and Eastern Mediterranean regions' shortages are projected to decrease by only 7% and 15%, respectively. CONCLUSIONS: The latest NHWA data show progress in the increasing size of the health workforce globally as more jobs are and will continue to be created in the health economy. It however masks considerable inequities, particularly in WHO African and Eastern Mediterranean regions, and alarmingly among the 47 countries on the WHO Support and Safeguards List. Progress should be acknowledged with caution considering the immeasurable impact of COVID-19 pandemic on health workers globally.

Estimating the health workforce requirements and costing to reach 70% COVID-19 vaccination coverage by mid-2022: a modelling study and global estimates.

OBJECTIVES: The implementation of COVID-19 vaccination globally poses unprecedented stress to health systems particularly for countries with persisting health workforce shortages prior the pandemic. The present paper estimates the workforce requirement to reach 70% COVID-19 vaccination coverage in all countries by mid-2022 using service target-based estimation. METHODS: Health workforce data from National Health Workforce Accounts and vaccination coverage reported to WHO as of January 2022 were used. Workload parameters were used to estimate the number of health workers needed with a service target-based approach, the gap and the scale-up required partially accounting for countries' challenges, as well as the associated costs in human resources. RESULTS: As of 1 January 2022, only 34 countries achieved 70% COVID-19 vaccination coverage and 61 countries covered less than a quarter of their population. This analysis showed that 1 831 000 health workers working full time would be needed to reach a global coverage of 70% COVID-19 vaccination by mid-2022. To avoid severe disruptions to health system, 744 000 additional health workers should be added to domestic resources mostly (77%) in low-income countries. In a sensitivity analysis, allowing for vaccination over 12 months instead of 6 months would decrease the scale-up to 476 000 health workers. The costing for the employment of these 744 000 additional health workers is estimated to be US$2.5 billion. In addition to such a massive scale-up, it is estimated that 29 countries would have needed to redeploy more than 20% of their domestic workforce, placing them at serious risk of not achieving the mid-year target. CONCLUSION: Reaching 70% global coverage with COVID-19 vaccination by mid-2022 requires extraordinary efforts not before witnessed in the history of immunisation programmes. COVID-19 vaccination programmes should receive rapid and sustainable investment in health workforce.

Uses of population census data for monitoring geographical imbalance in the health workforce: snapshots from three developing countries.

BACKGROUND: Imbalance in the distribution of human resources for health (HRH), eventually leading to inequities in health services delivery and population health outcomes, is an issue of social and political concern in many countries. However, the empirical evidence to support decision-making is often fragmented, and many standard data sources that can potentially produce statistics relevant to the issue remain underused, especially in developing countries. This study investigated the uses of demographic census data for monitoring geographical imbalance in the health workforce for three developing countries, as a basis for formulation of evidence-based health policy options. METHODS: Population-based indicators of geographical variations among HRH were extracted from census microdata samples for Kenya, Mexico and Viet Nam. Health workforce statistics were matched against international standards of occupational classification to control for cross-national comparability. Summary measures of inequality were calculated to monitor the distribution of health workers across spatial units and by occupational group. RESULTS: Strong inequalities were found in the geographical distribution of the health workforce in all three countries, with the highest densities of HRH tending to be found in the capital areas. Cross-national differences were found in the magnitude of distributional inequality according to occupational group, with health professionals most susceptible to inequitable distribution in Kenya and Viet Nam but less so in Mexico compared to their associate professional counterparts. Some discrepancies were suggested between mappings of occupational information from the raw data with the international system, especially for nursing and midwifery specializations. CONCLUSIONS: The problem of geographical imbalance among HRH across countries in the developing world holds important implications at the local, national and international levels, in terms of constraints for the effective deployment, management and retention of HRH, and ultimately for the equitable delivery of health services. A number of advantages were revealed of using census data in health research, notably the potential for producing detailed statistics on health workforce characteristics at the sub-national level. However, lack of consistency in the compilation and processing of occupational information over time and across countries continues to hamper comparative analyses for HRH policy monitoring and evaluation.

Assessing human resources for health: what can be learned from labour force surveys?

BACKGROUND: Human resources are an essential element of a health system's inputs, and yet there is a huge disparity among countries in how human resource policies and strategies are developed and implemented. The analysis of the impacts of services on population health and well-being attracts more interest than analysis of the situation of the workforce in this area. This article presents an international comparison of the health workforce in terms of skill mix, sociodemographics and other labour force characteristics, in order to establish an evidence base for monitoring and evaluation of human resources for health. METHODS: Profiles of the health workforce are drawn for 18 countries with developed market and transitional economies, using data from labour force and income surveys compiled by the Luxembourg Income Study between 1989 and 1997. Further descriptive analyses of the health workforce are conducted for selected countries for which more detailed occupational information was available. RESULTS: Considerable cross-national variations were observed in terms of the share of the health workforce in the total labour market, with little discernible pattern by geographical region or type of economy. Increases in the share were found among most countries for which time-trend data were available. Large gender imbalances were often seen in terms of occupational distribution and earnings. In some cases, health professionals, especially physicians, were overrepresented among the foreign-born compared to the total labour force. CONCLUSIONS: While differences across countries in the profile of the health workforce can be linked to the history and role of the health sector, at the same time some common patterns emerge, notably a growing trend of health occupations in the labour market. The evidence also suggests that gender inequity in the workforce remains an important shortcoming of many health systems. Certain unexpected patterns of occupational distribution and educational attainment were found that may be attributable to differences in health care delivery and education systems; however, definitional inconsistencies in the classification of health occupations across surveys were also apparent.

Monitoring and evaluation of human resources for health: an international perspective.

BACKGROUND: Despite the undoubted importance of human resources to the functions of health systems, there is little consistency between countries in how human resource strategies are monitored and evaluated. This paper presents an integrated approach for developing an evidence base on human resources for health (HRH) to support decision-making, drawing on a framework for health systems performance assessment. METHODS: Conceptual and methodological issues for selecting indicators for HRH monitoring and evaluation are discussed, and a range of primary and secondary data sources that might be used to generate indicators are reviewed. Descriptive analyses are conducted drawing primarily on one type of source, namely routinely reported data on the numbers of health personnel and medical schools as covered by national reporting systems and compiled by the World Health Organization. Regression techniques are used to triangulate a given HRH indicator calculated from different data sources across multiple countries. RESULTS: Major variations in the supply of health personnel and training opportunities are found to occur by region. However, certain discrepancies are also observed in measuring the same indicator from different sources, possibly related to the occupational classification or to the sources' representation. CONCLUSION: Evidence-based information is needed to better understand trends in HRH. Although a range of sources exist that can potentially be used for HRH assessment, the information that can be derived from many of these individual sources precludes refined analysis. A variety of data sources and analytical approaches, each with its own strengths and limitations, is required to reflect the complexity of HRH issues. In order to enhance cross-national comparability, data collection efforts should be processed through the use of internationally standardized classifications (in particular, for occupation, industry and education) at the greatest level of detail possible.

The role of wages in the migration of health care professionals from developing countries.

Several countries are increasingly relying on immigration as a means of coping with domestic shortages of health care professionals. This trend has led to concerns that in many of the source countries - especially within Africa - the outflow of health care professionals is adversely affecting the health care system. This paper examines the role of wages in the migration decision and discusses the likely effect of wage increases in source countries in slowing migration flows.This paper uses data on wage differentials in the health care sector between source country and receiving country (adjusted for purchasing power parity) to test the hypothesis that larger wage differentials lead to a larger supply of health care migrants. Differences in other important factors affecting migration are discussed and, where available, data are presented.There is little correlation between the supply of health care migrants and the size of the wage differential between source and destination country. In cases where data are available on other factors affecting migration, controlling for these factors does not affect the result.At current levels, wage differentials between source and destination country are so large that small increases in health care wages in source countries are unlikely to affect significantly the supply of health care migrants. The results suggest that non-wage instruments might be more effective in altering migration flows.

Developing evidence-based ethical policies on the migration of health workers: conceptual and practical challenges.

It is estimated that in 2000 almost 175 million people, or 2.9% of the world's population, were living outside their country of birth, compared to 100 million, or 1.8% of the total population, in 1995. As the global labour market strengthens, it is increasingly highly skilled professionals who are migrating. Medical practitioners and nurses represent a small proportion of highly skilled workers who migrate, but the loss of health human resources for developing countries can mean that the capacity of the health system to deliver health care equitably is compromised. However, data to support claims on both the extent and the impact of migration in developing countries is patchy and often anecdotal, based on limited databases with highly inconsistent categories of education and skills.The aim of this paper is to examine some key issues related to the international migration of health workers in order to better understand its impact and to find entry points to developing policy options with which migration can be managed.The paper is divided into six sections. In the first, the different types of migration are reviewed. Some global trends are depicted in the second section. Scarcity of data on health worker migration is one major challenge and this is addressed in section three, which reviews and discusses different data sources. The consequences of health worker migration and the financial flows associated with it are presented in section four and five, respectively. To illustrate the main issues addressed in the previous sections, a case study based mainly on the United Kingdom is presented in section six. This section includes a discussion on policies and ends by addressing the policy options from a broader perspective.

Geography of child mortality clustering within African families.

After decades of sustained child mortality reductions, infant and early childhood mortality levels in Africa remain high. This can partly be ascribed to the concentration of child mortality within particular families, communities or geographic localities. Strong mortality clustering is indicative of marked social inequality and of an unequal distribution of health and health-related resources and infrastructures. It also signifies a concentration of nutritional and sanitary behaviors harmful to the good health and longevity of children. Finally, it likely points to the existence of particular genetic problems in certain families, or environmental problems within specific communities. Using nationally representative family level data from all sub-regions of Africa, two important findings emerge from this study. First, levels of mortality have generally declined in all countries over time, and as mortality decreases, mortality clustering tends to follow the same trend. Second, bio-demographic covariates have a more important effect on familial mortality clustering risks than socio-economic ones.

Data on the migration of health-care workers: sources, uses, and challenges.

The migration of health workers within and between countries is a growing concern worldwide because of its impact on health systems in developing and developed countries alike. Policy decisions need to be made at the national, regional and international levels to manage more effectively this phenomenon, but those decisions will be effective and correctly implemented and evaluated only if they are based on adequate statistical data. Most statistics on the migration of health-care workers are neither complete nor fully comparable, and they are often underused, limited (because they often give only a broad description of the phenomena) and not as timely as required. There is also a conflict between the wide range of potential sources of data and the poor statistical evidence on the migration of health personnel. There are two major problems facing researchers who wish to provide evidence on this migration: the problems commonly faced when studying migration in general, such as definitional and comparability problems of "worker migrations" and those related to the specific movements of the health workforce. This paper presents information on the uses of statistics and those who use them, the strengths and limitations of the main data sources, and other challenges that need to be met to obtain good evidence on the migration of health workers. This paper also proposes methods to improve the collection, analysis, sharing, and use of statistics on the migration of health workers.