Towards universal health coverage: a health workforce fit for purpose and practice
James Campbell a
a. Instituto de Cooperación Social Integrare, Calle Balmes 30, 3°-1, 08007 Barcelona, Spain.
Correspondence to James Campbell (e-mail: firstname.lastname@example.org).
Bulletin of the World Health Organization 2013;91:887-888. doi: http://dx.doi.org/10.2471/BLT.13.126698
The finality of universal health coverage (UHC) is to ensure that all people are able to access the quality health services they need without suffering undue financial hardship. Margaret Chan describes it as the ultimate expression of fairness.1 The italicized words above should therefore frame the starting point for a contemporary discourse on human resources for health in the post-2015 development agenda for health (2015–2030).
UHC is an aspirational concept. It establishes what is to be achieved but says little on how to get there.2 However, the first step in accelerating progress towards UHC – building a health workforce that is both fit for purpose and fit to practice – is relatively simple. How does one go about it? By developing the competencies and regulatory frameworks needed to deliver quality care in accordance with the burden of disease and health priorities. The planning and implementation lens is ex ante: What health workforce do we need by 2030 to attain “effective coverage”3–7 of an agreed package of care that meets the needs of all people, be they rich or poor? This line of questioning, which is increasingly evident,8 generates the strategic intelligence to inform evidence-based decisions on human resources for health. Once need is quantified, a secondary but important policy consideration is pragmatism surrounding the available human and capital resources and fiscal space within national settings. Such pragmatism can inform the pace of acceleration towards UHC but should not undermine the initial workforce visioning process or the obligation of governments to deliver on the right to health.9
Existing thresholds for the required number of professional health workers (midwives, nurses and physicians) per 1000 population – 2.28 and 3.45 according to the World Health Organization (WHO) and the International Labour Organization, respectively10–12 – provide valuable references for translating need into indicative workforce requirements, but they should be considered part of the process of planning the workforce to meet the needs of the population rather than an absolute target in countries currently below these thresholds. To promote effective coverage and deliver services closer to the client, it is essential to further analyse the availability or supply of the workforce; its accessibility in spatial, temporal and financial terms; its acceptability to clients; and its quality, in terms of performance. This entails using internationally recognized standards to classify the different occupations in the health workforce; gaining a better understanding of the health labour market within a country; moving beyond counting health workers to assessing their full-time equivalent and available working time; and being more cognisant of the skill mix – and educational pathways – required for the workforce to become fit for purpose.
To an extent, The Kampala declaration and agenda for global action and the WHO Global Code of Practice on the International Recruitment of Health Personnel offer existing global benchmarks.13,14 The accountability report from the meeting of the G8 held in June 2013 in Lough Erne, Northern Ireland, provides evidence that some countries are monitoring their recommended actions.15 However, the international community has yet to fully grasp the inherent value of these documents in fostering accountability. The 2013 progress report on the Global Code of Practice, for example, is a sober reminder that existing health workforce recommendations are not being implemented at scale in all WHO regions.16
A contemporary strategy on human resources for health, embedded within the post-2015 development agenda for health, is needed to accelerate progress towards UHC. Such a strategy should promote effective coverage with health services staffed by a workforce that is both fit for purpose and fit to practice. This requires an accompanying accountability and reporting mechanism not only for tracking the stock or density of the health workforce or the coverage of health interventions, but for collating disaggregated data on the availability, accessibility, acceptability and quality of the workforce to meet population needs, ensure the delivery of quality care and achieve fairness for all.
- World Health Organization [Internet]. Chan M. Universal coverage is the ultimate expression of fairness. Geneva: WHO; 2012. Available from: http://www.who.int/dg/speeches/2012/wha_20120523/en/index.html# [accessed 16 August 2013].
- Giedion U, Alfonso EA, Díaz Y. The impact of universal coverage schemes in the developing world: a review of the existing evidence. Washington: The World Bank; 2013 (UNICO Studies Series No. 25). Available from: http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Images/IMPACTofUHCSchemesinDevelopingCountries-AReviewofExistingEvidence.pdf [accessed 20 August 2013].
- Shengelia B, Tandon A, Adams OB, Murray CJL. Access, utilization, quality, and effective coverage: an integrated conceptual framework and measurement strategy. Soc Sci Med 2005; 61: 97-109 http://dx.doi.org/10.1016/j.socscimed.2004.11.055 pmid: 15847965.
- Tanahashi T. Health service coverage and its evaluation. Bull World Health Organ 1978; 56: 295-303 pmid: 96953.
- Campbell J. The route to effective coverage is through the health worker: there are no shortcuts. Lancet 2013; 381: 725 http://dx.doi.org/10.1016/S0140-6736(13)60579-6 pmid: 23472917.
- Background paper for the Technical Consultation on Effective Coverage of Health Systems. Geneva: World Health Organization; 2001. Available from: http://www.who.int/health-systems-performance/technical_consultations/effcov_background.pdf [accessed 16 August 2013].
- 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 http://dx.doi.org/10.1371/journal.pmed.1001368 pmid: 23335862.
- Ono T, Lafortune G, Schoenstein M. Health workforce planning in OECD countries: a review of 26 projection models from 18 countries. Ferney-Voltaire: OECD; 2013. Available from: http://www.oecd-ilibrary.org/content/workingpaper/5k44t787zcwb-en [accessed 16 August 2013].
- Ooms G, Brolan C, Eggermont N, Eide A, Flores W, Forman L, et al., et al. Universal health coverage anchored in the right to health. Bull World Health Organ 2013; 91: 2-2A http://dx.doi.org/10.2471/BLT.12.115808 pmid: 23397341.
- The world health report 2006: working together for health. Geneva: World Health Organization; 2006. Available from: http://www.who.int/whr/2006/en/ [accessed 24 August 2013].
- Scheil-Adlung X. Health workforce benchmarks for universal health coverage and sustainable development. Bull World Health Organ 2013; 91: 888.
- Cometto G, Witter S. Tackling health workforce challenges to universal health coverage: setting targets and measuring progress. Bull World Health Organ 2013; 91: 881-885.
- Global Health Workforce Alliance. The Kampala declaration and agenda for global action. Geneva: World Health Organization; 2008. Available from: http://www.who.int/workforcealliance/knowledge/resources/kampala_declaration/en/ [accessed 16 August 2013].
- Resolution WHA63.16. WHO Global Code of Practice on the International Recruitment of Health Personnel. In: Sixty-third World Health Assembly, Geneva, 17–21 May 2010. Resolutions and decisions. Geneva: World Health Organization; 2013. Available from: http://apps.who.int/gb/ebwha/pdf_files/WHA63-REC1/WHA63_REC1-P2-en.pdf [accessed 16 August 2013].
- Gov.UK [Internet]. Lough Erne accountability report: keeping our promises. London: G8 UK; 2013. Available from: https://www.gov.uk/government/publications/lough-erne-accountability-report [accessed 16 August 2013].
- A 66/25. The health workforce: advances in responding to shortages and migration, and in preparing for emerging needs: report by the Secretariat. In: Sixty-sixth World Health Assembly, Geneva, 20–28 May 2013. Geneva: World Health Organization; 2013. Available from: http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_25-en.pdf [accessed 16 August 2013].