Mit Philips and Marielle Bemelmans of Médecins Sans Frontières discuss the looming issue of how to afford an expanded health workforce in the countries that need it most
The Seventieth World Health Assembly is currently underway in Geneva, Switzerland, where, among other things, a recently presented Five-Year Action Plan for Health Employment and Inclusive Economic Growth 2017-21 developed from the Global Strategy on Human Resources for Health: Workforce 2030 will be discussed. Together, the global strategy and the action plan address issues around severe shortages and uneven distribution of health workers globally. Oddly, while the action plan highlights the positive economic benefits of investing in human resources for health (HRH), it largely fails to address economic constraints to its implementation. It touts the potential tremendous economic returns on improving HRH without adequately addressing the financial investment needed, particularly the lack of funds for recurring costs such as salaries—an unrealistic promise of huge returns with minimal investment.
The intended addition of 40 million jobs in the health and social sector is expected to mainly meet the demand in high and middle income countries. However, the projected shortfall of 18 million health worker jobs in 2030 will largely fall in low and middle income countries. Moreover, this gap is underestimated due to the chosen definition for ‘demand’ as based on affordability within the country’s domestic resources.
Several of the action plan’s recommendations refer to expanding the number of health workers through increased investment in training and ‘life-long learning’. While laudable, it is not enough. Although the shortage of health workers can in part be addressed through increased and improved supply, experience suggests that significant numbers of existing trained workers cannot enter the public health sector, often due to limited finances and fiscal space to absorb and remunerate them adequately in the public payroll.
A substantial part of the health workforce in many poor countries is not on the official payroll. In Sierra Leone, 9,350 health workers—approximately half of the professional health workforce—are unpaid volunteers, often waiting years for recruitment in the public sector. A similar situation exists in Guinea  and in Mozambique, where over the past eight years thousands of health professionals have been paid through temporary bridge funding by international development partners whilst awaiting absorption into the Ministry of Health payroll. The renewed interest in task-shifting to Community Health Workers overlooks the need to formalize their roles beyond being unpaid volunteers and improve their supervision, support and career development; they too face inadequate remuneration and poor working conditions.
Systematic underfunding of health workers in the public health system also leads to downstream financial barriers to patient access through staff dependence on patient fees. The health system in Guinea largely relies on patients’ out-of-pocket payments to complement low state salaries or payment to “volunteers”. In Sierra Leone patient payments demanded by these volunteers undermine the application of the Free Health Care Initiative. Because patients are more likely to be able to pay in larger cities, this reinforces the uneven urban-rural distribution of staff.
Whilst the action plan constructively highlights several important problems, it fails to address critical points related to who will finance the recommended plans. The global strategy asserts that domestic resources for HRH “should be supported by appropriate macroeconomic policies at national and global levels” while admitting that at least in certain circumstances “countries will require overseas development assistance for a few more decades to ensure adequate … fiscal space” (part 38). However, the action plan and the global strategy specify neither the number of countries needing continued international support nor the criteria to assess such needs. Further, the action plan does not recognise the need for flexible use of international funds to (bridge) fund salaries in the short term and otherwise circumvent damaging fiscal restrictions. Neither the action plan nor the global strategy recommend measures necessary to increase fiscal space.
As international aid for health continues to flat-line or decrease, the assumption that expanding health services relies on increases of domestic funding, even in resource-limited settings, underlies current international aid discourse . However, such reliance on domestic funding remains unrealistic in most countries. In Lesotho, where international donors previously supported approximately 500 (lay) counsellors, in 2012 over half stopped working due to reduction of funds and lack of absorption capacity of the government. This negatively impacted HIV testing programs. Similarly, HIV testing rates in Kwazulu Natal, South Africa, dropped by at least 25% when the government phased out the lay counselor cadre in 2015.
Countries struggling to address existing and new health challenges need sustained international support and other measures to address underlying inequities on the global health workforce distribution. We have seen how country-based initiatives to strengthen the health workforce can successfully pool international and domestic resources. For example, in Malawi an emergency HRH program (2004-2010) increased the investment in salary top-ups and training for health workers, leading to a 53% increase in the number of health workers in the country. However, after these efforts, initiatives stalled and the increase in health workers has not kept with population growth; Malawi had 1.99 doctors per 100,000 population in 2009 but that ratio decreased to 1.79 in 2016. While fertility rates are decreasing in Africa, its population is expected to more than triple during this century, a dynamic which should be taken into account in workforce planning.
How do we ensure the effort to create jobs and economic opportunities includes actual public health benefits for people affected by ill health in low resource contexts? While we welcome the global momentum towards investing in the health workforce, we fail to see how the action plan could drive intended public health changes without including measures to lift or circumvent macro-economic constraints such as on wage bill expenditures. The improvement and expansion of training cannot translate into expansion of public services for those who need it most unless we assure absorption of workers into the public system. Rather, such workers may simply expand the private sector or boost the international brain drain.
To achieve increased access to free, quality services that advance the health status of everyone, including those most in need, the World Health Assembly and its member states need to address the elephant in the room. Otherwise the health workforce ambitions risk being trampled.
 Philips M., Dying of the Mundane in the Time of Ebola: The effect of the epidemic on health and disease in West Africa. Chapter 5 in The Politics of Fear. Médecins Sans Frontières and the West African Ebola Epidemic. Oxford University Press 2017.
 MSF (2016). HRH Assessment Malawi – internal report. Brussels, Belgium: Analysis and Advocacy Unit, Medecins Sans Frontieres.
Mit Philips is a medical doctor with an MPH, who worked abroad during 15 years for Médecins Sans Frontières and since 2000 is based at MSF’s headquarters in Brussels as health policy advisor in the Analysis Department, with a focus on global health policies and health in fragile states. She also was part of the team of Health Policy and Planning the Institute of Tropical Medicine in Antwerp, Belgium (2010-2012).
Marielle Bemelmans, PhD, is a public health professional with over 15 years experience in international health, mostly working for MSF with a focus on Human Resources for Health (HRH), health policy analysis and advocacy. Since April 2017, Marielle is the new director of Wemos Foundation, the Netherlands.
Featured image credit: Erik (HASH) Hersman, Flickr