Working together for health

There can be no doubt that there is a growing health workforce crisis in many parts of the world. The global population is rising, but the number of health workers is stagnating or even falling in ratio.

WHO estimates the current global health workforce to be around 59 million women and men. There are 39.5 million health service providers and over 19.5 million management and support workers. It is estimated that there is a global shortage of more than four million doctors, midwives, nurses, pharmacists, dentists and support workers. Decades of cost cutting and under-investment in health have also resulted in truly terrible working conditions for many in the health workforce. The morale and performance of overburdened, underpaid and unsupported health workers have sharply declined. As a result, many health workers feel they can no longer continue under these conditions. This has led to loss of health workers, deterioration of health services and erosion of public trust in the health system.

Solutions to these problems do exist, and new ones are being actively sought. Innovative and effective ways to educate, support and manage the health workforce, and encourage private-public partnerships are already reaping benefits. In recent years, WHO and its partners have moved health workforce issues up the political agenda. To give further momentum to efforts in this area, World Health Day 2006, the world health report 2006, have all been aligned around the key theme of Working together for health. The hope is that this will encourage all stakeholders -- policy makers, international donors, politicians, health professionals, academia, civil society, faith-based organisations, media -- to unite and work together to strengthen the health workforce.

The four priorities for action encompass educating and training health workers; supporting and protecting them; enhancing their effectiveness; and tackling health imbalances and inequities.

Educating and training health workers
What can we do to educate and train health workers? All countries, poor or rich, should develop updated comprehensive national plans to identify health workforce shortages and bottlenecks, and develop a consensus for joint action. Plans should respond to health needs and personnel requirements , as well as the changing nature of labour markets and the new skills mixes required. In all these areas, rational and innovative new approaches will be needed. Approaches that have already yielded good results in many countries include:

• adapting education and training curricula to fit national health priorities;
• improving coordination and planning between the health, education and finance sectors;
• continued training and support for health professionals;
• diversifying the roles of health workers; and
• creating new health worker categories, along with new education programmes.

Supporting and protecting the health worker community
What can we do to support and protect health workers? Suppor-ting and protecting health workers requires competitive salaries and other benefits , good working conditions (including flexible working hours) and a workplace safe from the risks of infection, injury and violence.

In addition to the risks associated with infection and workplace accidents, health workers face the added threat of violence. A shift towards a "zero-tolerance" app-roach to violence against health workers and its systematic reporting is one of the most important issues in protecting health workers, and one that needs to be addressed now.

Successfully mobilising support from both the public and private sectors will also be a key part of retaining health workers. Building up the capacity for ongoing training, encouraging career advancement, and providing managerial support are all urgent priorities. Not all strategies for supporting and protecting health workers require large-scale financial investment or infrastructure.

Enhancing the effectiveness of the health workforce
What can we do to enhance health workforce effectiveness? Strate-gies to enhance the effectiveness of the health workforce must initially focus on existing staff because of the time lag in training new health workers. In the short-term, one challenge will be improving health worker performance and impact by matching skills to health needs while maintaining professional standards and codes of conduct. In the longer term, sustained improvements are only likely if they are accompanied by improved working conditions, salaries and management as well as workplace policies that support life-long learning.

A team approach to patient care should be encouraged. Innovative approaches to turn individual health workers into members of health teams, backed by effective and supportive supervision, should be implemented. Recognising the contribution of all health workers and finding efficient ways for them to contribute will be vital if significant gains are to be made.

But it is not just the formal workforce that can be better managed for improved performance. For example, in Thai village health volunteers perform primary health care and disseminate health information in their communities. In return they receive non-financial incentives, such as social recognition and continuous training. Such innovative and cost-effective ideas can enable informal health workers worldwide to carry out basic yet life-saving functions such as drug distribution, health surveillance and outreach programmes.

If implementing these and other approaches is to be successful, it will be vital to gain trust. Without trust, health systems cannot be fully effective. Fighting corruption in all its guises must therefore be a priority if trust in state health systems is to be regained.

Tackling imbalances and inequities
The global shortage of health workers is currently estimated at 4.25 million. The world health report 2006 has shown that in general, countries with fewer than 2.3 doctors, nurses and midwives per 1000 people fail to achieve an 80 percent coverage rate for measles immunisation, or the presence of skilled birth attendants during childbirth. This has a demonstrable impact on people's lives and deaths. Fifty-seven countries fall below this minimum threshold, mainly in sub-Saharan Africa and Asia.

What can we do to tackle imbalances and inequities?
Strategies must be developed to manage internal and international migration, and make health work a safer and more attractive occupation. Where appropriate, the statutory age of retirement should be re-considered and made more responsive to an era of ageing workforces. Whatever approaches are adopted there should be a focus on protecting health in the poorest countries while ensuring individual freedom of movement.

Countries must work both individually and together to find solutions. Governments should invest in their health systems, particularly the workforce, in order to attract and retain sufficient health personnel to meet the health needs of their populations

In order to manage international migration and minimize inequities, action will be required in source countries, receiving countries, and internationally.

Source country strategies: Source countries can employ a wide range of strategies for managing migration, including:

• Adjusting training to needs -- Training that is focused on local conditions can help to retain health workers. Success here will depend upon a wide range of on-the-job incentives and support, and the involvement of key institutions such as universities and professional associations.
• Improving local conditions Improving the employment conditions of workers helps to remove the "push" factors that induce workers to migrate.
• Making it easy for health workers to return home after working abroad -- Surveys show that many migrant workers eventually want to come back home, either to work or to retire. Mechanisms to make proper use of their skills and knowledge should be sought.

Receiving country strategies: Receiving countries should demonstrate concern for the rights and welfare of migrant health workers by:

• Adopting responsible recruitment policies -- Receiving countries have a responsibility to recognise that significant investments were made in source countries in training health care professionals, and their absence may have immediate and adverse effects.
• Providing support to human resources in source countries -- Many receiving countries are also providers of overseas development assistance for health. Support could be more directly targeted at expanding the health workforce, thus stemming the impact of outgoing migration.
• Ensuring the fair treatment of migrant workers -- Migrant workers should be recruited on terms and conditions equal to those of locally recruited staff.

Dr. Md. Iqbal Kabir is a public health specialist and epidemiologist