What steps can improve and promote investment in the health and care workforce? Enhancing efficiency of spending and rethinking domestic and international financing

The European Observatory on Health Systems and Policies is a partnership that supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of health systems in the European Region. It brings together a wide range of policy-makers, academics and practitioners to analyse trends in health reform, drawing on experience from across Europe to illuminate policy issues. The Observatory’s products are available on its website (https://healthobservatory.eu). What steps can improve and promote investment in the health and care workforce? Enhancing efficiency of spending and rethinking domestic and international financing POLICY BRIEF 54 Barbara McPake Prarthna Dayal Julia Zimmermann Gemma A Williams World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 E-mail: eurocontact@who.int Website: www.euro.who.int HEALTH SYSTEMS AND POLICY ANALYSIS Print ISSN 1997-8065 Web ISSN 1997-8073 PolicyBrief_PB_54_COVER_PRINT.qxp_Cover_policy_brief 21/03/2023 10:54 Page 1 Keywords: HEALTH MANAGEMENT AND PLANNING PERSONNEL STAFFING AND SCHEDULING - organization and administration HEALTH POLICY HEALTH SYSTEMS PLANS – organization and administration INTERSECTORAL COOPERATION This policy brief is one of a new series to meet the needs of policy-makers and health system managers. The aim is to develop key messages to support evidence-informed policy-making and the editors will continue to strengthen the series by working with authors to improve the consideration given to policy options and implementation. What is a Policy Brief? A policy brief is a short publication specifically designed to provide policy makers with evidence on a policy question or priority. Policy briefs • Bring together existing evidence and present it in an accessible format • Use systematic methods and make these transparent so that users can have confidence in the material • Tailor the way evidence is identified and synthesised to reflect the nature of the policy question and the evidence available • Are underpinned by a formal and rigorous open peer review process to ensure the independence of the evidence presented. Each brief has a one page key messages section; a two page executive summary giving a succinct overview of the findings; and a 20 page review setting out the evidence. The idea is to provide instant access to key information and additional detail for those involved in drafting, informing or advising on the policy issue. Policy briefs provide evidence for policy-makers not policy advice. They do not seek to explain or advocate a policy position but to set out clearly what is known about it. They may outline the evidence on different prospective policy options and on implementation issues, but they do not promote a particular option or act as a manual for implementation. © World Health Organization 2023 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies) All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full. Please address requests about the publication to: contact@obs.who.int. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies or any of its partners concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the European Observatory on Health Systems and Policies in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the European Observatory on Health Systems and Policies to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the European Observatory on Health Systems and Policies or any of its partners be liable for damages arising from its use. The views expressed by authors or editors do not necessarily represent the decisions or the stated policies of the European Observatory on Health Systems and Policies or any of its partners. The Policy Brief Series 1. How can European health systems support investment in and the implementation of population health strategies? David McDaid, Michael Drummond, Marc Suhrcke 2. How can the impact of health technology assessments be enhanced? Corinna Sorenson, Michael Drummond, Finn Børlum Kristensen, Reinhard Busse 3. Where are the patients in decision-making about their own care? Angela Coulter, Suzanne Parsons, Janet Askham 4. How can the settings used to provide care to older people be balanced? Peter C. Coyte, Nick Goodwin, Audrey Laporte 5. When do vertical (stand-alone) programmes have a place in health systems? Rifat A. Atun, Sara Bennett, Antonio Duran 6. How can chronic disease management programmes operate across care settings and providers? Debbie Singh 7. How can the migration of health service professionals be managed so as to reduce any negative effects on supply? James Buchan 8. How can optimal skill mix be effectively implemented and why? Ivy Lynn Bourgeault, Ellen Kuhlmann, Elena Neiterman, Sirpa Wrede 9. Do lifelong learning and revalidation ensure that physicians are fit to practise? Sherry Merkur, Philipa Mladovsky, Elias Mossialos, Martin McKee 10. How can health systems respond to population ageing? Bernd Rechel, Yvonne Doyle, Emily Grundy, Martin McKee 11. How can European states design efficient, equitable and sustainable funding systems for long-term care for older people? José-Luis Fernández, Julien Forder, Birgit Trukeschitz, Martina Rokosová, David McDaid 12. How can gender equity be addressed through health systems? Sarah Payne 13. How can telehealth help in the provision of integrated care? Karl A. Stroetmann, Lutz Kubitschke, Simon Robinson, Veli Stroetmann, Kevin Cullen, David McDaid 14. How to create conditions for adapting physicians’ skills to new needs and lifelong learning Tanya Horsley, Jeremy Grimshaw, Craig Campbell 15. How to create an attractive and supportive working environment for health professionals Christiane Wiskow, Tit Albreht, Carlo de Pietro 16. How can knowledge brokering be better supported across European health systems? John N. Lavis, Govin Permanand, Cristina Catallo, BRIDGE Study Team 17. How can knowledge brokering be advanced in a country’s health system? John. N Lavis, Govin Permanand, Cristina Catallo, BRIDGE Study Team 18. How can countries address the efficiency and equity implications of health professional mobility in Europe? Adapting policies in the context of the WHO Code and EU freedom of movement Irene A. Glinos, Matthias Wismar, James Buchan,Ivo Rakovac 19. Investing in health literacy: What do we know about the co-benefits to the education sector of actions targeted at children and young people? David McDaid 20. How can structured cooperation between countries address health workforce challenges related to highly specialized health care? Improving access to services through voluntary cooperation in the EU Marieke Kroezen, James Buchan, Gilles Dussault, Irene Glinos, Matthias Wismar 21. How can voluntary cross-border collaboration in public procurement improve access to health technologies in Europe? Jaime Espín, Joan Rovira, Antoinette Calleja, Natasha Azzopardi-Muscat, Erica Richardson,Willy Palm, Dimitra Panteli 22. How to strengthen patient-centredness in caring for people with multimorbidity in Europe? Iris van der Heide, Sanne P Snoeijs, Wienke GW Boerma, François GW Schellevis, Mieke P Rijken. On behalf of the ICARE4EU consortium 23. How to improve care for people with multimorbidity in Europe? Mieke Rijken, Verena Struckmann, Iris van der Heide, Anneli Hujala, Francesco Barbabella, Ewout van Ginneken, François Schellevis. On behalf of the ICARE4EU consortium 24. How to strengthen financing mechanisms to promote care for people with multimorbidity in Europe? Verena Struckmann, Wilm Quentin, Reinhard Busse, Ewout van Ginneken. On behalf of the ICARE4EU consortium 25. How can eHealth improve care for people with multimorbidity in Europe? Francesco Barbabella, Maria Gabriella Melchiorre, Sabrina Quattrini, Roberta Papa, Giovanni Lamura. On behalf of the ICARE4EU consortium 26. How to support integration to promote care for people with multimorbidity in Europe? Anneli Hujala, Helena Taskinen, Sari Rissanen. On behalf of the ICARE4EU consortium 27. How to make sense of health system efficiency comparisons? Jonathan Cylus, Irene Papanicolas, Peter C Smith 28. What is the experience of decentralized hospital governance in Europe? Bernd Rechel, Antonio Duran, Richard Saltman 29. Ensuring access to medicines: How to stimulate innovation to meet patients’ needs? Dimitra Panteli, Suzanne Edwards 30. Ensuring access to medicines: How to redesign pricing, reimbursement and procurement? Sabine Vogler, Valérie Paris, Dimitra Panteli 31. Connecting food systems for co-benefits: How can food systems combine diet-related health with environmental and economic policy goals? Kelly Parsons, Corinna Hawkes 32. Averting the AMR crisis: What are the avenues for policy action for countries in Europe? Michael Anderson, Charles Clift, Kai Schulze, Anna Sagan, Saskia Nahrgang, Driss Ait Ouakrim, Elias Mossialos 33. It’s the governance, stupid! TAPIC: a governance framework to strengthen decision making and implementation Scott L. Greer, Nikolai Vasev, Holly Jarman, Matthias Wismar, Josep Figueras 34. How to enhance the integration of primary care and public health? Approaches, facilitating factors and policy options Bernd Rechel 35. Screening. When is it appropriate and how can we get it right? Anna Sagan, David McDaid, Selina Rajan, Jill Farrington, Martin McKee 36. Strengthening health systems resilience: key concepts and strategies Steve Thomas, Anna Sagan, James Larkin, Jonathan Cylus, Josep Figueras, Marina Karanikolos 37. Building on value-based health care Peter C Smith, Anna Sagan, Luigi Siciliani, Dimitra Panteli, Martin McKee, Agnès Soucat, Josep Figueras 38. Regulating the unknown: A guide to regulating genomics for health policy-makers Gemma A Williams, Sandra Liede, Nick Fahy, Kristiina Aittomaki, Markus Perola, Tuula Helander, Martin McKee, Anna Sagan 39. In the wake of the pandemic: Preparing for Long COVID Selina Rajan, Kamlesh Khunti, Nisreen Alwan, Claire Steves, Trish Greenhalgh, Nathalie MacDermott, Anna Sagan, Martin McKee 40. How can we transfer service and policy innovations between health systems? Ellen Nolte, Peter Groenewegen 41. What are the key priority areas where European health systems can learn from each other? Johan Hansen, Alexander Haarmann, Peter Groenewegen, Natasha Azzopardi Muscat, Gianpaolo Tomaselli, Mircha Poldrugovac 42. Use of digital health tools in Europe: Before, during and after COVID-19 Nick Fahy, Gemma A Williams, COVID-19 Health System Response Monitor Network 43. European support for improving health and care systems Nick Fahy, Nicole Mauer, Dimitra Panteli 44. What are patient navigators and how can they improve integration of care? Hannah Budde, Gemma A Williams, Giada Scarpetti, Marieke Kroezen, Claudia B Maier 45. What are the implications of policies increasing transparency of prices paid for pharmaceuticals? Erin Webb, Erica Richardson, Sabine Vogler, Dimitra Panteli 46. How can skill-mix innovations support the implementation of integrated care for people with chronic conditions and multimorbidity? Juliane Winkelmann, Giada Scarpetti, Gemma A Williams, Claudia B Maier 47. Addressing backlogs and managing waiting lists during and beyond the COVID-19 pandemic Ewout van Ginneken, Sarah Reed, Luigi Siciliani, Astrid Eriksen, Laura Schlepper, Florian Tille, Tomas Zapata 48. Does provider competition improve health care quality and efficiency? Luigi Siciliani, Martin Chalkley, Hugh Gravelle 49. Health system performance assessment: A primer for policy-makers Dheepa Rajan, Irene Papanicolas, Marina Karanikolos, Kira Koch, Katja Rohrer-Herold, Josep Figueras 50. Making Health for All Policies: Harnessing the co-benefits of health Scott L. Greer, Michelle Falkenbach, Luigi Siciliani, Martin McKee, Matthias Wismar, Praneetha Vissapragada, Marie C. Montás, Janamarie Perroud, Olivia Rockwell, Josep Figueras 51. How can the EU support sustainable innovation and access to effective antibiotics? Michael Anderson, Dimitra Panteli, Elias Mossialos 52. Global Health Workforce responses to address the COVID-19 pandemic Margaret Ziemann, Candice Chen, Rebecca Forman, Anna Sagan, Patricia Pittman 53. What can intersectoral governance do to strengthen the health and care workforce? Margaret Caffrey, Tara Tancred, Joanna Raven The European Observatory has an independent programme of policy briefs and summaries which are available here: https://eurohealthobservatory.who.int/publications/policy-briefs PolicyBrief_PB_54_COVER_PRINT.qxp_Cover_policy_brief 21/03/2023 11:55 Page 2 Editors Gemma Williams Michelle Falkenbach Anna Sagan Matthias Wismar Series Editor Anna Sagan Managing Editors Jonathan North Lucie Jackson The European Observatory is non- normative and offers evidence and options but does not make recommendations. This policy brief, however, has been developed with WHO HQ and Regions in the context of the 5th Global Forum on Human Resources for Health. The key messages therefore go beyond the standard European Observatory approach and assert what should be done. These messages, while they are more directive than ‘usual’, are supported by rigorous analysis of the evidence. Contents Acknowledgements 2 List of abbreviations 3 List of figures, boxes and tables 4 Towards an evidence-informed statement of intent: 5 key messages on investing in workforce development Executive Summary 7 Policy Brief 9 1. Introduction 9 2. Where can strategic investments be targeted 10 to help build a more sustainable HCWF? 3. How can we ensure sufficient funding is 22 available for strategic investments in the HCWF? 4. Conclusions and policy considerations 29 for the future References 33 Authors Barbara McPake – Nossal Institute for Global Health at the Melbourne School of Population and Global Health Prarthna Dayal – Nossal Institute for Global Health at the Melbourne School of Population and Global Health Julia Zimmermann – European Observatory on Health Systems and Policies Gemma A Williams – European Observatory on Health Systems and Policies page What steps can improve and promote investment in the health and care workforce? Print ISSN 1997-8065 Web ISSN 1997-8073 PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 1 2Policy brief Acknowledgements This policy brief was developed under the overall strategic and technical guidance of (in alphabetical order): Michelle Falkenbach, Suszy Lessof, Dheepa Rajan, Gemma A. Williams and Matthias Wismar (European Observatory on Health systems and Policies); and James Campbell and Rania Kawar (WHO Headquarters). The authors would like to extend thanks to the following individuals for providing technical inputs and feedback on the report (in alphabetical order, by region and name): James Asamani and Juliet Nabyonga-Orem (WHO Regional Office for Africa); Juan Pablo Pagano and Claudia Pescetto (WHO Regional Office for the Americas); Juana Bustamante Izquierdo, Laurence Codjia, Giorgio Cometto, Khassoum Diallo, Meredith Fendt-Newlin, Siobhan Fitzpatrick, Catherine Kane, Paul Marsden, Michelle McIsaac, Tana Wuliji and Pascal Zurn (WHO Headquarters); Gulin Gedik and Awad Mataria (WHO Regional Office for the Eastern Mediterranean); Maggie Langins, Cris Scotter and Tomas Zapata (WHO Regional Office for Europe); Ibadat Dhillon (WHO Regional Office for South East Asia); and Masahiro Zakoji (WHO Regional Office for the Western Pacific). The European Observatory on Health Systems and Policies wishes to thank the external reviewers of the report, Monica Georgiana Brînzac (Babeș-Bolyai University, Cluj-Napoca, Romania) and a reviewer who wishes to remain anonymous. Special thanks are also extended to authors of country/regional case studies (in alphabetical order): Benin: Arnaud Gislain Hollo, Agnès Vissoh Ayadji, Anita Wadagni (Ministry of Health, Benin); Laurence Codjia (WHO Headquarters) European Union: Nicole Mauer (European Observatory on Health Systems and Policies) Ghana: Brian Wong (European Observatory on Health Systems and Policies) Iran: Amirhossein Takian (Tehran University of Medical Sciences, Iran); Gulin Gedik (WHO Regional Office for the Eastern Mediterranean); Shadrokh Sirous (WHO Country Office in Iran) Ireland: Rachel Kenna (Chief Nursing Officer, Ireland) and Gráinne Sheeran (Office of the Chief Nursing Officer, Ireland). Thanks are also extended to Brian Wong and Julia Zimmermann (European Observatory on Health Systems and Policies) for reviewing country case studies; and to Candice Chen, Patricia Pittman and Margaret Ziemann (George Washington University, US) for contributing to sections on workforce diversity, migration and gender equity. The authors extend enormous gratitude to Jonathan North and Lucie Jackson for managing the production process, and to Andrea Kay for copyediting the report. PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 2 3What steps can improve and promote investment in the health and care workforce? List of abbreviations APSS Asia Pacific Spine Society COVID-19 coronavirus disease 2019 CPD continuing professional development EU European Union FHT Family Health Team GCNO Government Chief Nursing Officer GoG Government of Ghana HCWF health and care workforce HNP health, nutrition and population HRH human resources for health HCWs health and care workers IADB Inter-American Development Bank IPE interprofessional education IMF International Monetary Fund LMICs low- and middle-income countries MOU memorandum of understanding NCD noncommunicable diseases OECD Organisation for Economic Co-operation and Development PCT primary care team PFM public financial management PFP pay-for-performance PPE personal protective equipment SDG Sustainable Development Goals SDR Special Drawing Rights STEM science, technology, engineering and mathematics UHC universal health coverage W4H Working for Health WHO World Health Organization PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 3 4Policy brief List of figures, boxes and tables Figures Figure 1: A typical configuration of a PCT according to 13 McCauley et al. (2021) Figure 2: Classification of compulsory service programme 15 Figure 3: The annual inflows of foreign-trained doctors 17 and nurses in selected OECD countries has slightly increased in recent years Figure 4a: Over 25% of nurses work in privately owned 18 facilities in some countries Figure 4b: In a small number of countries over 10% of 18 medical doctors work in privately owned facilities Figure 5: The United States has consistently been the 27 largest funder of development assistance for HRH, but contributions from other countries and Foundations are growing Boxes Box 1: Methods 10 Box 2: A CAN$ 200 million Action Plan to retain, train 10 and recruit HCWs in Manitoba, Canada Box 3: Primary health care in Iran has been reformed 13 helping to improve patient outcomes and access Box 4: Investment in nursing in Ireland 14 Box 5: There are a number of well-known mechanisms 22 to create fiscal space for health Box 6: Ghana Investment in the HCWF during 23 the COVID-19 pandemic Box 7: Budget efficiency in the health sector can be 26 improved through a number of actions Box 8: The EU has a number of financing mechanisms 27 available to Member States and third countries for HCWF reforms Box 9: Concessional financing in Benin to improve 28 access to services and progress towards UHC Tables Table 1: Dual practice typology 19 Table 2: Continuing medical education compared 20 with CPD as paradigms Table 3: Payment systems to improve performance 21 PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 4 What steps can improve and promote investment in the health and care workforce? – education infrastructure, faculty, competency-based education models and online learning to support HCWF development and economies more widely; – continuing professional development (CPD) and lifelong learning, aligned with international standards to respond to changing needs; – the multidisciplinary teams and skills necessary to deliver primary care and fill gaps in underserved and hard-to-reach areas efficiently and effectively. 3. Investment will be wasted if the HCWF is not supported and protected and workers leave the sector • The pandemic demonstrated that a range of measures can effectively protect the HCWF and sustain them. • Investing in the protection of all existing workers is crucial if the HCWF is to be retained, which means: – paying for decent working conditions; – taking steps to support the mental and physical health of the HCWF; – managing staff performance and supporting career development; – removing the gender pay gap, where it exists, delivering equal pay and targeting gender inequalities. • The HCWF is not sustainable if adequate employment opportunities are not available. • At the half-way point of the SDGs there are inequities and paradoxes: – the HCWF accounts for 10% of total employment in high-income countries (but only a little over 1% in LMICs); – LMICs experience both a shortage of HCWF relative to population needs, and unemployment or underemployment of health and care workers (HCWs) • Coordinated investments – both domestic and international are needed to stimulate health labour markets and HCW employment opportunities including by: – adjusting labour market investments to stimulate job creation. – initiatives to offset demand issues; – fair remuneration. • Adequate financial and non-financial incentives need to be combined with policies that support and protect HCWs, especially women and youth. 4. Solidarity and cooperation at the multilateral, regional and domestic levels is needed to secure sufficient and sustained investment • Securing long-term domestic financing for recurrent HCWF costs relies on demonstrating efficiency, but an underfunded HCWF cannot be effective and optimize performance. 5 Towards an evidence-informed statement of intent: key messages on investing in workforce development The lessons of resource mobilization during the COVID-19 pandemic show what is possible. There is an urgent need for countries and international actors to apply those lessons to secure sufficient funding for health and care workforce (HCWF) education, employment and retention. Investment needs to 2030 are negligible in comparison to government spending during COVID-19. There is powerful evidence that developing a sustainable HCWF will help deliver on the ambitions of universal health coverage (UHC), health security and the Sustainable Development Goals (SDGs) and generate exceptional dividends and co-benefits. If governments are to take forward the policies and practices that work, they should know the following. 1. Oversupply of health and care workers is the only solution to current challenges and only top-level political leaders’ commitment can secure investment in the HCWF on the scale needed • Political leaders proved during COVID-19 that remarkable things are possible. • Now only top-level political leadership can ensure the financial commitment necessary to break the cycle of shortages and attrition. Leaders need to recognize: – decades of underinvestment have led to a workforce crisis that requires urgent action; – low- and middle-income countries (LMICs) face significant shortages and high-income countries with rising population demand are a long way from self- sufficiency; – the macroeconomic outlook and threat of economic stagnation in many countries is a challenge but cannot be allowed to undermine collective action. • The evidence from the pandemic – that the HCWF generates invaluable contributions to the economy, decent employment, gender rights, societal health and well-being and health security – needs to be used to convince finance ministries that the HCWF matters. • Health must be at the decision-making table when finances are allocated to get investments to where they need to be. 2. Investing in education supports the HCWF, creates human capital and expands access • The pandemic showed how adaptable the HCWF can be and how important it is to develop their competencies, skills and adaptability. • Societies need to invest in education and training that develops health systems’ capacity for health and care services and public health functions, and that drives wider benefits in health sciences, technologies and research. Key measures include investing in: – secondary education and in science and technology skills, particularly for girls, to provide candidates for the HCWF and create human capital; PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 5 6Policy brief • Policy-makers at all levels need to mobilize sufficient resources to attract, retain and motivate the HCWF and allow them to perform and this requires: – All governments to consider the cross-cutting benefits of effective education and retention policies for the HCWF in their spending decisions, (recognizing their contribution to gender equality, managing migration, economic participation and rural economies). – Governments to recognize the counter cyclical value of health employment. – Development assistance for the HCWF to be increased (from just 5%), including through intersectoral allocations from education, gender and job creation budgets. – Investment, including international development funding, should focus on creating a sustainable HCWF, with ideas to scale-up revenue for education and employment including more extensive debt cancellation and greater use of blended financing options. PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 6 7What steps can improve and promote investment in the health and care workforce? Executive summary COVID-19 has exposed chronic underfunding in the health and care workforce and shown the urgent need to protect and increase investment in education, recruitment and retention Decades of underinvestment in education, employment and retention has left a global undersupply of health and care workers (HCWs). By 2030 there will be an estimated shortage of some 10 million HCWs worldwide. While low- and middle-income countries (LMICs) will be most affected, the majority of high-income countries have not yet built a self-sufficient health and care workforce (HCWF); many are experiencing chronic shortages and skills mismatches, and some are reliant on recruiting foreign-trained workers to fill gaps. Despite progress, most countries are not yet supplying enough graduates for replacement and there is sometimes not enough economic demand to create jobs and pay wages. In some countries, there is a growing reliance on the private sector – who are not incentivized to keep costs in the health sector down – to fund education and recruitment, contributing to rising out-of-pocket spending. The COVID-19 pandemic has exposed insufficient investment in the HCWF and shown how unprepared health systems were to respond to a global health crisis. There is an urgent need for countries and international actors to prioritize investment in the HCWF and to ensure funding is used well. Without the right people and infrastructure, it is not possible for health systems to deliver high-quality and efficient care that is responsive to population health needs. An adequately trained and staffed HCWF is at the core of functional health systems that can respond to shocks and can support progress towards universal health coverage (UHC), health security and the Sustainable Development Goals (SDGs). Even as economic growth slows, education, employment and retention of HCWs needs to be a priority in public expenditure to increase supply, protect the existing workforce and plan ahead to address future challenges. With the estimated economic costs of COVID-19 amounting to US$47.7 trillion in lost output between 2020–2030, more than 17 times the estimated cost of making progress towards health-related SDG targets, the cost of failing to invest in the HCWF is likely to outweigh the cost of action. The case for investing in the HCWF is compelling. Political leadership has to ensure the HCWF is properly funded. Transforming education and training is an effective investment that can improve the quantity, skills and diversity of HCWs Insufficient investment in health professional education and training has led to an undersupply of HCWs globally and a lack of workforce capacity when needed during COVID-19. Greater investment in developing education and training capacity and improving quality is needed to produce HCWs in sufficient numbers and with required skills. While replenishing stock will likely require producing an oversupply of HCWs to overcome attrition issues, this will be a stimulant for human capital and skills development in all countries, irrespective of whether they end up in the health economy. Investment to increase the quantity, quality and diversity of the available HCWF needs to expand the pool of people qualified for careers in the health sector. This requires investment in young people not least by improving primary and secondary education, and promoting the varied careers health sectors can offer. The systems that educate health professional also need to be reformed, including by delivering interprofessional education (IPE), shifting towards competency-based curricula, greater use of online learning tools, aligning educational pathways and promoting stronger transitions from education to practice. More investment is also needed to ensure the availability of faculty and fit-for-purpose infrastructure and to develop appropriate regulation and accreditation, where feasible. Finally, investing in pathway programmes, mentorship and recruitment practices, can promote HCWF diversity, which is important for improving patient outcomes and for reaching underserved groups. Investing to produce sufficient graduates is not enough, action is also needed to enable them to find employment within the health sector, and to stay in health careers There is a large gap in the proportion of total jobs in the health and care sector between high-income countries and LMICs. The HCWF accounts for 10% of the total employment in high-income countries and a little over 1% in LMICs. Many LMICs face a paradox. On the one hand there is a shortage of HCWF relative to population needs, and on the other, health workers are unemployed or underemployed. This situation occurs when (government or private sector) purchasers’ willingness to pay is so low that there is insufficient demand for health workers. Coordinated investments will be required – both domestic and international – to stimulate the health labour markets in these countries and increase HCW employment opportunities. Financing the existing workforce is one of the best investments that can be made. If HCW are not supported, are burnt-out, overworked and feel undervalued, they will not be able to perform optimally and may drop out of the workforce entirely. This is a failure on behalf of employers. Investing in recruitment and retention strategies can help reduce attrition, protecting earlier investments in education. Investing in fair pay, decent working conditions, protection and support measures, and promoting career opportunities are important in retaining HCWs. This is especially so for women who make up a disproportionate share of the HCWF globally, but experience a substantial gender pay gap and are underrepresented in leadership roles. Managing performance also has a key role in motivating and retaining staff, and can be promoted through continuing professional development (CPD) and a mix of other incentives. Securing and mobilizing long-term, sustained levels of domestic financing for recurrent HCWF costs relies on demonstrating efficiencies of spending on initiatives such as those to enhance working environments and promote decent work, that may otherwise remain underfunded. PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 7 8Policy brief Investment to reskill and optimize the HCWF will help deliver quality primary care and public health, and improve service delivery in underserved areas An efficient and equitable health system is founded on strong primary health care and public health principles. Ageing populations in many regions, increasing chronic conditions globally and growing inequality mean the old skill mix is no longer fit for purpose. A preventive model of health care is needed with a focus on the “right” kinds of health workers. This requires investment in a new mix of skills and disciplines such as physiotherapy, speech therapists, dietetics, optometry, and many others, and to upscale use of digital health technologies. There is also a need for investment strategies that encourage HCWs to stay in country, in rural and remote areas, and in health sector jobs. Roles need to be made attractive to the right people, and this does not mean simply increasing salaries; job characteristics and career opportunities can be made attractive too. Non-financial as well as financial incentives are important to help address the negative impacts of maldistribution in rural and other underserved areas, and dual practice – where HCWs work in both the private and public sectors – can also reduce push factors for outward migration. It should nevertheless be emphasized that countries where health workers are first educated (“origin countries”) do not control many of the policy levers driving health professional migration, so destination countries need to play their part when recruiting internationally and should invest in strengthening their own education, recruitment and retention systems. The funding available for HCWF initiatives needs to be protected and may require additional resources There are many opportunities for countries to invest strategically in the HCWF and to ensure resources are used efficiently. Funding these options means protecting current investment and raising additional investment where needed. Every government needs to explore how to accelerate the use of domestic, regional and international financing towards the HCWF. Protecting public revenues will be particularly challenging in the post-pandemic economic climate, especially in LMICs. Creating fiscal space for investment in the HCWF should nevertheless be possible for most countries. However, some countries, particularly those in the global south, face constraints on their monetary sovereignty which limit their ability to act. Rethinking internally and externally imposed limitations on public spending by governments and multilateral organizations could allow countries to raise public revenues for much needed investment. The health sector needs to understand and be able to make the economic case for the HCWF to secure political leadership for investment Political leadership is a key condition to raising domestic resources. However, there is often pervasive underinvestment in the public sector as a whole, and especially in sectors such as health that employ large numbers of women and are consequently often undervalued by society. A narrative that presents the HCWF as an investment and not a cost can help argue for budgets for health and human resources for health (HRH) to be prioritized. There are many evidence-based arguments that may appeal to policy-makers and help make the economic case for greater investment in the HCWF. Stable and sufficient funding for the HCWF can drive inclusive economic growth. It creates jobs – especially for women, young people and in rural areas. It can drive innovation in productive industries such as pharmaceuticals, research and development and manufacturing and promote health and human capital development, social cohesion, social protection and health security. Greater monitoring and evaluation is needed to quantify how HCWF investment supports health, societal and economic outputs and attaining SDGs. There needs to be effective engagement with stakeholders across sectors to agree to prioritize and plan public investments in the HCWF Not only must health policy-makers be able to communicate effectively to ministries of finance, they need to collaborate with other domestic and external actors, especially as much of the funding to strengthen the HCWF sits within the education sector. Ministries of Health must be able to share the measurable benefits of workforce development to convince other sectors, which requires strong leadership and capacity. Improved intersectoral governance processes are also crucial in bringing together public, private and other stakeholders to plan and co-finance HRH investment plans. Inefficiencies in health sector budget cycle processes are often seen as undermining efficiency and the case for investment. In many countries a reliance on input-based or line-item budgeting using historic trends disconnects health budgets from actual health sector needs. While countries have been putting in place policies and systems to reform their public management systems, this is not an easy task and will take time. International organizations and governments should work together to increase available funding from external sources to develop the HCWF in LMICs Development assistance for the HCWF has traditionally made up a relatively low share of total development assistance (just over 5% prior to the pandemic) and has been skewed towards alleviating immediate skills gaps. It has tended not to tackle major issues such as the high costs of educating and employing HCWs, mobility or gender inequalities. An increase in the external source of funding in the short-to-medium term could help many countries reach HCWF-related goals. Funds need to support country priorities such as better remuneration, sustainable recruitment practices, strengthening HRH information systems and management capabilities. This requires countries to be able to identify their short- and long-term HCWF needs. It also depends on strong engagement and alignment of priorities between donors and recipient governments and between donors themselves. Development assistance should support long-term HCWF objectives and facilitate additional and sustained increases in domestic resourcing for the recurrent cost of developing and maintaining the HCWF. There are a range of options that are outside the control of health sector actors. However, global and national-level health stakeholders could make the “international” case for increased investment in the HCWF and for radical solutions. Ideas that health stakeholders might champion include more extensive debt cancellation; blended financing options; more International Monetary Fund (IMF) SDRs (Special Drawing Rights); changing sovereign credit ratings, and reducing tax avoidance. Bold measures are needed to enable countries to raise resources to spend on health and to tackle the looming HCWF crisis, and health ministries must advocate courageously. PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 8 9What steps can improve and promote investment in the health and care workforce? 1. Introduction Chronic underfunding over years has taken its toll on the health and care workforce (HCWF) and substantial efforts are needed to scale-up investment and improve efficiency of spending In 2016, the World Health Organization (WHO) published the Global Strategy on Human Resources for Health. It recognized that without adequately available, accessible, acceptable and quality human resources for health (HRH), universal health coverage (UHC) and the Sustainable Development Goals (SDGs) cannot be attained (WHO, 2016a). The coronavirus disease 2019 (COVID-19) pandemic has also highlighted the chronic underfunding of the HCWF and demonstrated how unprepared health systems were to respond to a global health crisis (Deussom et al., 2022). The pandemic has underscored the critical importance of ensuring an adequately trained and sufficiently staffed HCWF is in place for functional and resilient health systems that can manage a pandemic, prevent and respond to future shocks to health systems, and meet growing and changing population health needs (Guillén, Buissonnière & Lee, 2021; Zapata, Buchan & Azzopardi-Muscat, 2021; Haldane et al., 2021; Czabanowska & Kuhlmann, 2021). Decades of underinvestment in education, employment and retention has left a global undersupply of health and care workers (HCWs). The Global Strategy projected a global shortage of 18 million health workers by 2030, which has recently been revised to 10 million (Boniol et al., 2022). Yet even this growth in HRH since 2013 has been uneven and countries with the poorest health outcomes and greatest inequity have shown the least growth. While low- and middle-income countries (LMICs) are most affected by shortages, high-income countries have not yet built a self- sufficient HCWF; many are experiencing chronic shortages and skills mismatches, and some recruit foreign-trained workers to fill gaps. Countries globally are not supplying enough graduates for replacement and there is sometimes not enough economic demand to create jobs and pay wages, especially in LMIC. In some countries, this has contributed to a growing reliance on the private sector – who are not incentivized to keep costs in the health sector down – to fund education and recruitment, contributing to rising out-of-pocket spending. Chronic underinvestment in health and other social sectors is universal across high-middle- and low-income countries. A reluctance to prioritize and adequately fund the HCWF is in part due to a belief that the health sector consumes more resources than socially optimal and does not contribute to achieving economic and fiscal objectives (Cylus et al., 2018; Cometto & Campbell, 2016). The report of the High-Level Commission on Health Employment and Economic Growth challenged this belief and made a strong case for investing in the HCWF globally, to help strengthen health systems, economies and societies (WHO, 2016b). The COVID-19 pandemic has only made the need for this investment more urgent, and has emphasised that the cost of inaction is much larger than the cost of action (WHO, 2016b). It is estimated that the cumulative cost of the COVID-19 pandemic over 2020–2030 in lost output alone is $47.7 trillion, not counting the value of lives lost (WHO Council on the Economics of Health for All, 2021). This is more than 17 times the estimated cost of making progress towards SDG 3 targets (Stenberg et al., 2017). Moreover, global poverty has also risen for the first time in over 25 years, with an estimated 88 to 115 million people pushed into extreme poverty in 2020 (World Bank, 2022b). With slowing economic growth in the aftermath of the COVID-19 crisis, countries and the global health community need to work together to prioritize investment in HCWF education, employment and retention and to ensure funding is used well. Investing strategically through reforms that demonstrate value for money and where efficiency of spending is maximized can cost-effectively help build a HCWF that is fit for purpose. Strategic investing requires efforts to protect and support the existing workforce, as well as funding health labour market reforms to stimulate employment and to drive improvements in education. Countries also need to move beyond a focus on numbers of doctors, nurses, midwives alone and closely examine the wider range of disciplines required in the future to deliver high-quality health care (Maier, 2022). HCWF needs are changing as health systems undergo various transitions – economic, demographic, epidemiological and social – which require changes to how health services have been traditionally delivered. With ageing populations, a rise in chronic conditions and growing inequality, it is critical to consider how to ensure an oversupply of graduates to meet health sector needs; what kinds of health workers can deliver the health services needed; are more likely to stay in country, in rural and remote areas, and in health sector jobs; and what support they need to deliver high-quality services effectively. Addressing current deficiencies in health systems and building a sufficient HCWF that can respond to the evolving health needs requires rethinking of the ways in which the HCWF have traditionally been trained, deployed and managed. It is well understood that an efficient and equitable health system is founded on strong primary health care and public health principles. The objective to strengthen primary health care and focus on a preventative model of health care that substantially reduces out-of-pocket spending and the inefficient use of public funds at higher levels of the system, and increases the quality, accessibility and continuity of care is therefore the challenge which health workforce plans need to align with and support. Even while highlighting the critical importance of HRH, the COVID-19 pandemic has put unprecedented pressure on government budgets due to the economic fallout. Projections show that the global demand for health workers is due to rise to 80 million workers by 2030 (Liu et al., 2017). At a time of slower economic growth and rising debt, countries will need to make strategic investments in future health workforce development to maximize efficiency of spending, and to protect existing resources and raise additional revenues where needed to fund rising HRH costs. POLICY BRIEF PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 9 10 Policy brief In this policy brief, we aim to answer two critical questions: 1) What are the best strategic investments that countries can make in education, employment and retention to increase the efficiency of their spending and create an adequate and fit-for-purpose HCWF for the future? 2) How can countries and international actors ensure sufficient resources are in place and are effectively targeted to fund HCWF reforms in a time of increasing constraints on public finances? These two questions are answered in turn in the next two sections, before we offer concluding remarks on the way forward. The methods used in his brief are outlined in Box 1. Box 1. Methods A scoping review of peer reviewed and grey literature was conducted across key English-language publications. Databases and online repositories searched include PubMed, Scopus, Web of Science, Google Scholar, WHO data collections and the European Observatory on Health Systems and Policies website. The literature search focused on two areas: 1) current thinking and innovations in the organiza- tion, training, deployment and management of the HCWF to provide policy options to countries as they develop HRH strategies and plans; 2) domestic and international financing mechanisms that can be used to help scale-up investment in the health workforce. Additionally, we drew from case studies compiled across different WHO regions. These case studies were put together by country experts who are listed in the Acknowledgement section of this brief. 2. Where can strategic investments be targeted to help build a more sustainable HCWF? Financial investments should be strategically targeted towards interventions that can most effectively enhance the sustainability of the HCWF and its ability to meet future health shocks and population health needs. Interventions that can support the achievement of these targets can broadly be grouped into strategies that: 1) aim to increase the quantity, quality and diversity of available HCWs through investments in education; 2) aim to reskill and optimize use of the HCWF through investments in preventative and primary care, skill mix reforms and use of digital technologies; 3) aim to improve employment and retention through labour market interventions and protecting, supporting and managing the HCWF. Inevitably, achieving efficiency in the allocation of available funds will vary for each country. Moreover, not all interventions will be relevant for all countries and will depend on their health labour markets, health system maturity and structure, population and geographical needs and economic status. However, in almost all countries, addressing HRH challenges will require efforts to target funding across all three areas. For example, a recent Human Resource Action Plan developed by the Province of Manitoba in Canada recognizes that investment in retaining, training and recruiting health care staff would all be necessary to overcome HCWF shortages (Box 2). Key interventions for targeting strategic investments are introduced in the remainder of this section, according to these three areas. We do not aim to cover all aspects of implementing these interventions, but instead to provide an overview of why they represent areas for strategic investment. Box 2. A CAN$ 200 million Action Plan to retain, train and recruit HCWs in Manitoba, Canada The Province of Manitoba, Canada faces a shortage of HCWs and retention challenges that have ben exacerbated by the COVID-19 pandemic. To help strengthen the health system and overcome HRH challenges, the Provincial Government in November 2022 have committed CAN$200 million to fund a Human Resource Action Plan. The Plan is based on three pillars to retain, train and recruit HCWs – focusing initially on doctors and nurses. The Plan adopted a number of strategies recommended by Doctors Manitoba and the Manitoba Nurses Union after a consultation process. The retention pillar aims to ensure existing staff are supported and protected in order to provide safe and accessible services. Actions include (among others): hourly premiums for working weekends, an end to mandated overtime, support for mental health counselling, reimbursing licensing fees, remote location incentives, enhanced security for emergency departments.The training pillar aims to train staff at all levels. Actions include (among others): expanding undergraduate education to cover nurses returning from retirement and foreign-trained workers; increasing the number of psychiatry and psychology positions; increasing intake for doctor and nursing education.The recruiting pillar aims to reduce barriers to recruitment. Actions include (among others): financial incentives for retired nurses to return; tuition rebates; reforming testing costs for returners; modernizing a Memoradum of Understanding (MOU) with Philippines for international recruitment. Source: Gordon, 2022 PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 10 11 What steps can improve and promote investment in the health and care workforce? 2.1 Investing in education to increase the quantity, quality and diversity of available HCWs 2.1.1 Investing in youth and promoting careers in the health sector The first step to increase the quantity, quality and diversity of the available HCWF is to invest in expanding the pool of people qualified for careers in the health sector. The HRH2030 Health Worker Life Cycle Approach to build, protect and manage a resilient health workforce in the aftermath of COVID-19 highlights the need to start with investing in young people – with a special focus on women in particular – to engage their interest and create a diverse candidate pool for health professional training programmes (Deussom et al., 2022). While there is not substantial evidence yet on strategies that work in this area, ideas include investing in STEM education both at the primary and secondary school levels and encouraging students, especially students from rural areas and girls, to study these subjects; providing leadership and volunteer opportunities to youth in community public health, internship opportunities in health departments or health facilities; advising on career pathways in health for students from a diverse range of backgrounds that can contribute to the health sector; and providing employment to secondary school graduates in less specialized sectoral work and supporting their upskilling over time (Deussom et al., 2022). 2.1.2 Investing in reforming education systems Greater investment in education is needed to produce an oversupply of graduates to meet population health needs Underinvestment in education and training in some countries, including high-income countries, has resulted in inadequate numbers of graduates to meet population health demands (Buchan, Catton & Shaffer, 2022; WHO Regional Office for Africa, 2021; WHO Regional Office for Europe, 2022). While the number of graduates has seen an overall increase over the past several years there is wide variability in the production of HCWs across countries, and declines in midwifery and primary care graduates have been observed in central Asia, Europe and in the United States (IHS Markit, 2021; WHO, 2022a). Regions with the lowest nursing graduation rates (Africa, Eastern Mediterranean, South-East Asian) also have the lowest nurse density. Meanwhile, future projections by Okoroafor et al. (2022) show that in Africa an estimated 6.1 million more physicians, nurse and midwives will be needed to meet population health demands by 2030; however, only 3.1 million will be trained and ready for service if current educational trajectories are maintained. In 2010, the Lancet Commission on health professional education estimated that global spending on health professional education and training was approximately US$ 100 billion (Frenk et al., 2010). This amounted to just 2% of total health expenditure and was deemed insufficient to meet health system needs. Greater investment in developing education and training capacity and improving quality is needed to produce HCWs in sufficient numbers and required skills. While replenishing stock will likely require producing an oversupply of HCWs to overcome attrition issues, this will be a stimulant for human capital and skills development in all countries, irrespective of whether they end up in the health economy. Interprofessional education, competency-based learning, curricula reform and using online learning tools can help strengthen health professional education In 2010, the Lancet Commission on health professional education called for the re-design of professional health education to meet the current challenges of the HCWF, based on a systems approach which recognizes the interdependence between education and health systems and the need to integrate efforts across the two (Frenk et al., 2010). It recommended several strategies to transform health professional education including a shift towards competency-based curricula adapted to local contexts, interprofessional education to promote collaboration, use of IT, strengthening of education resources including faculty, syllabuses, instructional materials and infrastructure, and instilling a culture of critical inquiry as a model of learning, and promotion of culturally competent care (Frenk et al., 2010). More resources are needed to strengthen the quality of education and train high-quality HCWs Accreditation is a common mechanism for improving standards in education. However, some countries do not see it as feasible within the constraints of their current capacities and resources, while others that have tried to implement accreditation have found it challenging. While countries work to improve their capacity for relying on accreditation as a means to improve education quality, they will need to look at increasing investments to address the challenges associated with poor quality of training. In many LMICs, lack of proper infrastructure and poor quantity and quality of teaching faculty have been cited as major impediments to improving the quality of health professional education (Efendi et al., 2018; Mullan et al., 2011; Bvumbwe & Mtshali, 2018). Bvumbwe and Mtshali (2018) reported that while many countries in sub-Saharan Africa have nursing councils as regulatory bodies, they lacked the capacity and resources required to be effective. At the same time, where the role of private health training institutions is large and/or growing, it is imperative that regulatory mechanisms focused on the private sector are strengthened. There is also a role for regional cooperation to enhance access to quality education. Asamani et al. (2022) for example, suggest that countries in Africa with capacity to train specialists, such as Kenya, Uganda, Tanzania and South Africa, could help develop programmes and capacity in other countries of the region. Online learning tools represent a cost-effective way to improve access to education, especially in rural areas The COVID-19 pandemic underscored the value of online learning tools to improve the reach and quality of health professional education, with medical and nursing colleges across the world quickly adapting to online curricula in the PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 11 12 Policy brief face of lockdowns. In resource-constrained settings in particular, online learning provides a cost-effective opportunity to address faculty shortages, increase the reach of both pre-service and in-service training, attract a more diverse student base, standardize and update content and encourage cross-institutional collaboration between better resourced and less resourced training institutes (Frehywot et al., 2013). There is a growing body of literature citing both the challenges as well as the lessons learned in maximizing the value of these online tools (Co, Chung & Chu, 2021; Gachanja, Mwangi & Gicheru, 2021; Nimavat et al., 2021). It will be important that countries learn from these emerging and growing experiences when considering the potential of online distance learning tools to meet their future HCWF needs. 2.1.3 Improving diversity of available HCWs to match population needs Investing to improve the diversity of the HCWF can help improve access to health services for underserved groups Advancing diversity in the health professions, inclusive of race/ethnicity, gender, socioeconomic status, rural back- ground and other minoritized communities, can help repair trust in health systems and meet population health needs. A developing body of work suggests racial concordance im- proves communication and patient satisfaction (Shen et al., 2018), and has the potential to improve patient outcomes (Alsa, Garrick & Graziani., 2019). Evidence also suggests di- versity can mitigate bias and positively influence practice in high need areas (van Ryn et al., 2015; Phelan et al., 2017; Goodfellow et al., 2016). Evidence-based strategies to im- prove the diversity of the health workforce include invest- ment in pipeline/pathway programmes to encourage and support future health careers, mentorship, recruitment and admission practices, student support services and financial support, and accreditation standards for diversity (Farrell et al., 2022). Ensuring diversity of the health workforce remains an ongoing challenge. In the United States, Black, Hispanic and Native American individuals are severely underrepresented in higher income health professions and conversely, overrepresented in lower wage health care occupations (Campbell et al., 2021a; Salsberg et al., 2021). In Canada, only 3.5% of medical students identified themselves as from an Aboriginal background compared with 7.4% of the population and only 6.4% grew up in a rural area whereas 18.7% of the population is rural (Khan et al., 2020). In Australia, there are an estimated 400 Indigenous doctors – less than 0.5% of doctors compared with 3% of the population (SBS News, 2021). The lack of diversity and inequities in the health workforce reflected broader structural injustices that also drove racial, ethnic, and socioeconomic disparities in COVID-19 outcomes and proved a major detriment to the eventual vaccine roll-out (Khanijahani et al., 2021; Willis et al., 2021). 2.2 Reskilling and optimizing the HCWF Meeting population health needs and progressing towards UHC requires investment to better target who to educate and train. Strengthening primary care and prevention functions and addressing gaps in the range of skills needed for this are a cost-effective investment for many countries. Similarly, developing mid-level cadres instead of just high- level cadres is likely to be less expensive and a more efficient way to meet population health needs. These strategies, in addition to other incentive packages, are likely to be especially effective to address inequities in rural and other underserved areas, which face some of the biggest shortages of HCWs globally. 2.2.1 Strengthening public health and primary health care Equitable and efficient health care systems are founded on strong primary care underpinned by team-based approaches to service delivery Delivering care in the right setting can help improve access and patient outcomes at lower cost. Since the 1978 Alma- Ata Declaration, investing in primary health care has widely been agreed upon as a cost-effective way to improve health outcomes, health system efficiency and health equity. Global consensus recognizes the gold standard of the primary care team (PCT) approach, especially in the context of epidemiological transition, growing multimorbidity and an ageing population. Efficient, accessible and high-quality primary care is best provided by a team of clinicians and other health professionals. While there is no standardized, or one-size-fits-all, approach, a typical configuration of a PCT (Fig. 1) includes a core team (purple), an extended health care team (blue) and an extended community care team (orange) (McCauley et al., 2021). One extended team may support several core teams. The PCT approach has been successfully adapted and implemented in communities worldwide, both in urban and rural settings. For example, a project established in Northern Bihar, on the border with Nepal, reported success in the activities of a community health team made up of experienced community health professionals, led by a community medicine specialist and including a registered nurse and several community health workers. This team combined to provide noncommunicable disease (NCD) management and holistic palliative care for those with advanced disease (Munday et al., 2019). Andrade et al. (2018) have described Brazil’s approach of Family Health Teams (FHTs) which deliver integrated and comprehensive primary health care, an approach which was launched in 1994. These teams are composed of a family physician, a nurse, a nursing assistant and 4–12 community health agents who are based at Health Units which operate in a geographical area covering a population of approximately 4 000 people. Similarly, Iran has invested in delivering team- based primary care, which has improved access to care and patient outcomes (Box 3). PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 12 13 What steps can improve and promote investment in the health and care workforce? Box 3. Primary health care in Iran has been reformed helping to improve patient outcomes and access Effective strategies to enable HRH are key to reaching UHC. Over past decades, Iran has used a range of initiatives to empower HRH, one such initiative was the scaling up of primary health care. Three concrete phases ensued to propel this initiative: First phase: Creation of health houses (Khaneh Behdasht), staffed by Behvarzes (community health workers based in rural health houses), which provide basic health services; each health house serves about 1 500 people within a 1-hour walking distance. Second phase: Family practices in rural areas and cities with a popula- tion of under 20 000 were developed, the quality of services was en- hanced through the appointment of new health workers (nutritionists, mental health experts and midwives). Third phase: Family practices in suburban areas and cities with a popu- lation of more than 20 000 were developed. This was made possible through public–private partnerships and the devolution of services to the nongovernmental sector. The impact of this initiative was substantial and can be grouped into four concrete outcomes: 1) maternal child health disparities between urban and rural populations were reduced; 2) noncommunicable dis- ease outcomes improved; 3) the population’s life expectancy grew by over 20 years since the creation of the Behvarz programme imple- mented in the first phase; 4) as a direct result of the increase in service providers during the second and third phases, the coverage of health services in urban areas, and the desire to receive various services includ- ing those for nutrition, mental health and NCD, expanded. A systematic review by O’Reilly et al. (2017) identified the challenges and enabling factors of a PCT approach in high- income countries. Challenges include that physicians are trained to manage patients individually rather than collectively and that traditional hierarchies can be a barrier to multidisciplinary care. Common enabling factors included clarity of roles and division of labour, frequent and respectful communication and being co-located. Similar challenges to team-based primary care were found in south India by Lall and colleagues (2020). 2.2.2 Investing in diversifying HCWF roles and skills More HCWs are needed in many contexts, and the mix of HCWs required is radically different from the mix that has been required in the past. The burden of disease in all regions is increasingly dominated by noncommunicable, chronic diseases shaped by social determinants. This requires health systems to transform from a mode that is responsive to episodes of illness predominantly in children, women of reproductive age and older adults, to one that maintains health and prevents the onset and progression of chronic illness, addresses risk factors across the life-cycle and takes a population perspective. Channelling resources into public health, prevention and early diagnosis can yield important Source: McCauley et al. (2021) Fig. 1. A typical configuration of a primary care team Health behavior supportCommunity health worker Social worker Care manager Pharmacist Dentist Early childhood specialist Behavioral health specialist Medical assistant Nurse School-based support Social support services Home health aide Patient & family Office staff PC clinician Core team Extended community care team Extended health care team PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 13 14 Policy brief productivity improvements and economic benefits, demonstrating an efficient use of investment. For example, it has been estimated that childhood immunizations in LMICs led to a return on investment of $44 for each $1 spent (Ozawa et al., 2016). Moreover, there was an estimated $10 return on investment for every $1 spent on community health workers in sub-Saharan Africa (Dahn et al., 2015). Moving towards a preventative model of care inevitably requires a rethinking of the skill mix and the set of disciplines extending from nursing and medicine into physiotherapy, dietetics, optometry, exercise science and many others. The old skill mix is no longer fit for purpose. However, workforce scarcity is a common challenge in many contexts. For example, in Ghana, there were only 55 dentists and 41 optometrists in the country in 2010, most of whom worked in the capital city (Ministry of Health, 2011). Some Asian countries have implemented PCTs with a more limited range of health workers to mitigate the workforce shortage. Overall, dentistry and pharmacy are more likely incorporated in PCTs than rehabilitation, diet and exercise, audiology or optometry professionals. As such, there is evidence that the HCWF as it is currently is unable to meet population needs in many countries (Burton et al, 2021). Role delegation is an important way to increase access to care given health workforce shortages, and improve efficiency. Different health professionals can be highly effective in delivering a wide range of services that have traditionally been delivered by physicians. For example, a 2013 systematic review suggested “no difference between the effectiveness of care provided by mid-level health workers in the areas of maternal and child health and communicable and noncommunicable diseases, and that provided by higher level health workers”. This conclusion is supported by other reviews and analyses (WHO Regional Office for South-East Asia, 2018b; Gajewski et al., 2019). These non-physician clinicians have not only been found to be effective, but also more likely to last in rural placements (Mullan & Frehywot, 2007). Many countries have already taken steps to invest in developing the skills of the non- physician workforce to support role delegation. One such example is Ireland, who have committed additional resources to develop the nursing workforce (Box 4). While PCTs are an efficient and effective way to deliver primary care, and options exist to mitigate some workforce shortages, more physicians, mid-level cadres and allied health professionals are needed to meet population health needs. This will require greater financial resources, more trainers, as well as the need to address quality and relevance of training (Couper et al., 2018). Box 4. Investment in nursing in Ireland In 2014, a Taskforce on Staffing and Skill Mix for Nursing was estab- lished in Ireland. The Taskforce was designed with five phases, each to focus on a different care area requiring specific safe staffing input. The core objective of the Taskforce was to develop a framework to support evidence-based determination of safe nurse staffing and skill mix. Phase 1 focused on Acute medical/surgical inpatient areas in hospital settings, followed by Phase 2: Emergency care settings. Each phase of the Framework provides a systematic, evidenced based approach to calculating the nursing care hours required by patients in the care setting, and was tested through a pilot programme to demonstrate impact. The research looked at patient, staff and organizational out- comes pre- and post-implementation of safe staffing recommenda- tions. Improved outcomes across all three categories were demonstrated and sustained over time. The final reports for Phases 1 and 2 (The Framework for safe nurse staffing and skill mix in general and specialist medical and surgical care settings in Ireland and The Framework for safe nurse staffing and skill mix in adult emergency care settings in Ireland) have been published (Department of Health, 2018), and Phase 3 has commenced in the non-acute general setting of long-term residential care settings for older persons. The Safe Staffing Framework (Phases 1 and 2) is now government policy and the responsibility for further development of the Frame- work (including Phase 3) is with the Government Chief Nursing Offi- cer (GCNO). The GCNO is also responsible for securing funding to ensure completed phases are implemented nationally. To date €25 million new funding has been allocated to the implementation of Phase 1 and €3.8 million new funding has been allocated to the im- plementation of Phase 2. The allocated funding provides for addi- tional staff required to implement the Framework, and for costs associated with information technology and education. The contin- ued evidence of better patient, staff and organizational outcomes demonstrated through implementation of the Framework is critical for securing ongoing investment. 2.2.3 Use of digital health tools Digital health tools offer enormous potential for all countries to cost-effectively strengthen primary care and public health and to respond effectively to emergency health threats Digital health applications such as telehealth, ePrescriptions, electronic health records, mHealth devices and artificial intel- ligence offer huge opportunities to improve the efficiency of the HCWF and to improve working conditions and outcomes for providers. Digital health tools can also promote patient empowerment, improve patient outcomes, accessibility, effi- ciency and quality of care delivery and the administration of the health system more widely (Fahy, Williams & COVID-19 Health System Response Monitor Network, 2021). The value of digital health tools in meeting various health system goals has been demonstrated during the COVID-19 pandemic, where they have been used to support surveillance and monitoring, provision of communication and information, supporting health care provision, and to help deliver vaccination programmes (see Fahy, Williams & COVID-19 Health System Response Monitor Network, 2021 and see the companion policy brief Global Health Workforce responses to address the COVID-19 pandemic by Ziemann et al., 2023 for more details). It will be important for countries PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 14 15 What steps can improve and promote investment in the health and care workforce? to build on this experience and put in place an enabling environment to support expanded use – such as necessary infrastructure, clear legal frameworks governing use, financial incentives to support uptake and developing digital strategies. Importantly, there is also a critical need to invest in upskilling and reskilling to ensure HCWs have the necessary competencies and motivation to use existing and emerging digital health technologies (Fahy et al., 2021). Rapid innovations in digital health technologies are also driving the need for new and emerging roles across clinical (e.g. in clinical informatics of cancer immunology), technical (e.g. digital specialist, systems architect) and future-oriented areas (e.g. AI experts, bioprinting experts). While developing these roles may not yet represent strategic areas for investment for many countries, for others, it may enable health systems to harness the huge efficiency gains and health improvements promised by digital technologies. 2.2.4 Improving the distribution of the HCWF in rural and other underserved areas Shortfalls in HRH and mismatches between available human resources and need for their services are substantial in many countries, especially in rural areas. Scheil-Adlung (2015) estimated that 77% of the rural population in Africa, 56% in the Middle East and 75% in Asia and the Pacific (excluding India and China) had no access to health care due to health worker shortages. This number was half or less than half in most regions for their urban counterparts. In 2021, WHO updated its guidelines on health workforce development, attraction, recruitment and retention in rural and remote areas. Strategies covered the areas of education, regulation, incentives and support. Random allocation systems miss the opportunity to post those who are happiest to serve in rural or remote positions Many countries use the practice of “posting” new graduates, which involves allocating new graduates to jobs without a recruitment or application process. Frehywot et al. (2010) provide a categorization of compulsory service programmes showing that “compulsory can be premised as a condition of service or employment, education programmes, license to practice, or can be attached to financial and non-financial incentives” (Fig. 2). Where no explicit national policy exists, some posting systems are non- transparent and not systematic (Purohit, Martineau & Sheikh, 2016), conducted solely at the discretion of local managers or have considerable variation between states and local government (Abimbola et al., 2017). Random allocation systems miss the opportunity to post those who are happiest to serve in rural or remote positions and who in turn are likely to have higher morale, better performance, less absenteeism and a lower rate of attrition once posted to them. For example, a Cochrane systematic review concludes that rural background is the factor most strongly associated with rural practice, lending strong support for HCWF development programmes that target rural trainees (Grobler et al., 2009; Ziemann et al., 2022). There is also evidence, including from the United States, the Democratic Republic of Congo (Fagan et al., 2015; Phillips, Petterson & Bazemore, 2013), Norway (reported in WHO, 2018), Bangladesh, China, India, Thailand and Viet Nam (Pudpong et al., 2017) that HCWs end up practicing close to their training sites, offering support for investments in community-based and rural training sites. Fig. 2 Classification of compulsory service programmes Source: Frehywot et al., 2010. Compulsory service 1. Condition of service/state employment programme Federal or state (employment contract) 2. Compulsory service with incentives Attached with financial and non-financial incentives 3. Compulsory service without incentives With no attached financial or non-financial incentives and not due to condition of service a. Educationally linked Country natives programme International medical graduate programme Before graduation programme as part of training requirement (rural placement to complete education) After graduation programme (to be able to specialize) Return of service for provided educational financial support) (mandatory rural placement after graduation b. Employment linked Licence to practise (public/private) Career advancement c. Living-provisions linked Housing allowance, car Ioan, children’s school, etc. d. Bundled programmes Combination of a, b or c PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 15 16 Policy brief Non-financial incentives can be more important than financial incentives in attracting HCWs to rural settings Alternatives to posting systems focus on the use of financial and non-financial incentives. There is inconclusive evidence surrounding financial incentives as the quality of the studies is generally considered poor. A common finding is that financial incentives need to be combined with other measures for positive impact (WHO, 2018). Non-financial incentives can be provided through preferential access to education, training and professional development opportunities. These have been considered more important than financial incentives in several settings including Thailand (Wibulpolprasert & Pengpaibon, 2003), but were not considered effective in Bangladesh (Rawal et al., 2015; Joarder et al., 2018). Other non-financial incentives that can be offered include housing and career advancement. HCWs in rural and remote areas will benefit from enhanced scopes of practice and continued training opportunities and psychosocial support Given the shortage of HCWFs in rural and remote areas, there is some emerging evidence that enhancing scopes of practice with proper training and regulation can assist HCWFs perform better and have greater job satisfaction. Often in rural areas the limited HCWF is called upon to deliver services that go beyond their formal training. WHO has recommended that governments formally recognize this role and provide proper support and compensation (WHO, 2021c). Further investing in rural health systems to raise the profile of health workers by social recognition programmes, facilitating collaboration and knowledge exchange and intentionally providing career pathways are all strategies to enhance the development and retention of rural health workers (WHO, 2021c). 2.3 Investing in employment and retention initiatives The Report of the United Nation’s High Level Commission on Health Employment and Economic Growth (WHO, 2016b) made 10 recommendations to transform the health workforce to achieve the SDGs, of which the first was urgent action to develop labour market policies to stimulate employment opportunities for the HCWF with a special focus on women and youth. Producing sufficient graduates is not enough, they need to be able to find employment within the health sector, and stay in health careers. Retention not only requires adequate financial and non- financial incentives but also policies that support and protect HCWs. Decent working conditions are important not only to attract people to work in the health sector; but also to ensure they can perform at their optimal potential. 2.3.1 Investing in the labour market to stimulate demand to employ HCWs There is a large gap between high-income countries and LMICs in the proportion of total jobs in the health and care sector – the HCWF accounts for 10% of the total employment in high-income countries and a little over 1% in LMICs (WHO & ILO, 2022). Many LMIC in particular face the paradoxical situation where there is a shortage of HCWF on the one hand relative to population needs, and unemployment or underemployment of health workers on the other (McPake et al., 2013). This situation occurs when there is insufficient demand for health workers as determined by the willingness to pay by the purchasers – government or private sector (Liu et al., 2017). In LMICs where the health sector continues to be dominated by the government sector, this gap in the willingness to pay is largely determined by the government’s fiscal capacity and ability to employ qualified health professionals. While the demand for the HCWF is projected to rise in high- and middle-income countries, in low-income countries this demand is estimated to remain stagnant, even though population needs are growing. This situation can also lead to outmigration of the HCWF from settings where they are needed the most to higher income countries with better pay and work conditions (Liu et al., 2017). Therefore coordinated investments will be required – both domestic and international – to stimulate the health labour markets in these countries and increase employment opportunities for the HCWF. These investments should be coordinated and coherent across multiple sectors – education, health, labour, trade, immigration – to ensure sufficient employment with good pay and working conditions, including for women and young people to be attracted as well as to stay in these jobs (WHO, 2016b). 2.3.2 Investing to address HCWF migration HCW migration results in substantial lost returns from educational investments Health professional migration is associated with worldwide shortages of HCWs (Aluttis, 2014), and lost returns on investment from outward migration are estimated to be substantial for source countries. For instance, the migration of doctors from Ethiopia, Kenya, Malawi, Nigeria, South Africa, Tanzania, Uganda, Zambia and Zimbabwe was estimated to accumulate lost returns from investment in education of $2.17bn (Mills et al., 2011). Substantial outward migration is an indicator of weak labour market absorptive capacity (Govindaraj, 2018). Low- and lower-middle-income countries produce about one third of foreign-trained HCWs. An OECD report found that in 10 African and Latin American countries, the emigration rates for native-born doctors exceeded 50% (OECD, 2020). However, when looking at emigration rates (ratio of domestically trained physicians abroad and total domestically trained physicians), four of the top 20 countries are in Europe (Estonia, Iceland, Ireland and Malta), five are in sub- Saharan Africa (Congo, Ethiopia, Ghana, Liberia and Zimbabwe) and the rest are in the Caribbean (Adovor et al., 2021). Data from the OECD show that inflows of foreign- trained doctors and nurses to OECD countries had plateaued to most countries between 2010 and 2018, rising in recent years (Fig. 3). The recent rise in health professional emigration can possibly be attributed to the COVID-19 pandemic. PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 16 17 What steps can improve and promote investment in the health and care workforce? Some countries have implemented policies to restrict HCW migration, while others capitalize on the advantages Some countries have also implemented a range of policies to restrict HCW migration or encourage return. For example, China has introduced a policy known as the “Young Thousand Talents” to attract highly educated Chinese nationals abroad back to the country (Marini & Yang, 2021). In Thailand, government-sponsored medical students trained overseas are required to return home (Tangcharoensathien et al., 2018a, 2018b). However, international migration of health workers offers career opportunities for HCWs and may benefit origin countries. For example, those who train with the intention of migration may not migrate immediately or at all, adding to the domestic HCWF. These professionals may have chosen a different career in the absence of opportunities to migrate. International migration of health professionals provides economic benefits to families who stay behind but benefit from remittances, and there are macroeconomic benefits associated through gross flow of remittances on aggregate demand. Philippines has been particularly opportunistic in capitalizing on these advantages and is the world’s largest supplier of nurses and remittances, which comprises nearly 10% of national GDP (World Bank, 2022a). Philippines, and other countries such as India, have favoured expanding access to health professional education with the expectation of serving both domestic and international needs (Thompson & Walton-Roberts, 2019). Investment is needed to address push factors for migration but destination countries need fair and mutually beneficial recruitment practices There is a “medical carousel” of international HCW migration (Bundred & Levitt, 2000), which might be better recognized as a ladder by which health professionals seek to migrate to countries with pay and conditions at least one rung up from where they are and more secure job conditions, and leave those countries at the bottom of the ladder denuded of health professionals (Doshmangir et al., 2022). This suggests a distribution of responsibility at all points on the ladder. In countries of destination, addressing push factors of migration in countries of origin, such as by improving working conditions, pay and providing career opportunities among others, are key areas for strategic investment to tackle migration-related challenges. Migration of health professionals is likely most responsive to policy in destination rather than origin countries, such as visa restrictions, diploma recognition, points-based migration systems, tax breaks and the availability of permanent residence status, hence the advocacy of restraint on the part of such countries in draining health workforce from the countries with the greatest shortfalls (Adovor et al., 2021; Drennan & Ross, 2019). Recruitment of international personnel should align with the WHO Global Code of Practice on International Recruitment of Health Personnel, which aims to ensure fair treatment of migrating health professionals, stop recruitment that would result in HCWF shortage in origin countries and encourages mutually beneficial government-to-government agreements (Clemens & Dempster, 2021). Fig. 3. The annual inflows of foreign-trained doctors and nurses in selected OECD countries has slightly increased in recent years Source: Author’s analysis based on data from OECD.Stat. 0 2 000 4 000 6 000 8 000 10000 12000 2014 2015 2016 2017 2018 2019 2020 Foreign trained doctors: annual inflow Australia Belgium Canada Chile France Germany Ireland Israel New Zealand Norway Spain Switzerland United Kingdom United States 0 2 000 4 000 6 000 8 000 10000 12000 2014 2015 2016 2017 2018 2019 2020 Australia Belgium Canada Chile France Germany Ireland Foreign trained nurses: annual inflow Israel New Zealand Norway Spain Switzerland United Kingdom United States PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 17 18 Policy brief 2.3.2 Investing to ensure optimal distribution between public and private providers Some countries have sizeable private sectors that influence HCWF challenges Lack of public investment and absorptive capacity in the public sector in some countries has led to increasing involvement of the private sector in delivering health care and employing HCWs (Govindaraj et al., 2018). While reporting to the National Health Workforce Accounts (WHO, 2023) on this issue is incomplete for the majority of countries, available data from reporting countries suggests the share of physicians and nurses working in private facilities is generally small in Africa and Europe, but several countries in the Americas, South-East Asia and Eastern Mediterranean regions have substantial private sectors that influence human resource challenges (Fig. 4). Dual practice is a particular form of competition between public and private sectors for the available health professionals in a country’s HRH stock It is well recognized that health professionals are not uniquely employed by either the public or private sector; substantial numbers engage in dual practice involving employment and work assignments in both sectors (McPake et al., 2016). Table 1 show the potential negative consequences of dual practice for reaching UHC and regulatory options to minimize these negative impacts on the public health sector to deliver services effectively. Fig. 4a Over 25% of nurses work in privately owned facilities in some countries Fig. 4b In a small number of countries over 10% of medical doctors work in privately owned facilities Notes: Data given for latest available year. Source: WHO, 2023. 0% 50% 100% Ba rb ad os Re pu bl ic c of K or ea U ni te d St at es of A m er ic a H ai ti Sa in t V in cc en t an d th e G re na di ne s Ec ua do r Eg yp t G ha na N ew Z ea la nd Jo rd an Br az il Ye m en N ig er ia C ze ch ia G uy an a A us tr al ia Ph ili pp pi ne s M al ay si a In di a Ira n (Is la m ic R ep ub lic o f) Ke ny a Za m bi a Q at ar A rg en tin a Es to ni a Es w at in il Rw an da Si ng ap or e Ba ng la de sh U ni te d A ra b Em ira te s U ru gu ay Le ba no n Pa ra gu ay Ku w ai t Zi m ba bw e % in p riv at e se ct or Country In di a Ba ng la de ss h Un ite d Ar ab E m ira te s Su rin am e N am ib ia Ur ug ua y So ut h Af ric a Tu ni sia Ira n (Is la m ic Re pu bl ic of ) Cz ec hi a Au st ra lia Ph ili pp in es Br az il M au rit iu s Rw an da Th ai la nd Bu ru nd i Ec ua do r Ar ge nt in a Fi nl an d Be ni n O m an Af gh an ist an Sa ud i A ra bi a To go Se ne ga l Ca m bo di a Zi m ba bw e 0% 50% 100% Ch ad % in p riv at e se ct or Country PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 18 19 What steps can improve and promote investment in the health and care workforce? The impacts of dual practice have parallels with the impacts of a growing private sector absorbing a country’s available health professional workforce by fully employing them and attracting them away from the public sector. This set of issues appears little recognized as they persist within monopsonistic public sector deployment systems, in which the public sector holds the monopoly purchasing role and health professionals have essentially no choice but to work for the government. Srinivasan and Chandwani (2014) report on the growing Indian private health sector’s human resource innovations that seek to attract the scarce talents needed by its hospitals and clinics with substantial focus on performance management, and reward and recognition systems. Similarly, in Costa Rica the private sector offers much better non- salary incentives to health workers, such as food, housing, legal defence etc., in addition to better working conditions in contrast to the limited nonmonetary incentives in the public sector. While dual practice is permitted as long as it happens outside of public sector work-hours, the reality is that with private practices coming up close to public facilities, it has been difficult to regulate this situation (Carpio & Bench, 2015). This further emphasizes the need to stimulate employment in the public sector and to invest in retention. Table 1. Dual practice typology UHC: universal health coverage. Source: McPake et al., 2016. Local conditions Types of dual practice observed Country example Potential negative con- sequences for UHC goal Type of regulatory options Limited ability and willingness to pay for health services Limited private sector development Blurred boundaries between public and private, large informal private sector Poor regulation and enforcing capacity Pervasive and unregulated dual practice, present in all its forms – outside, beside, within, as well as integrated to public services Bangladesh, Guinea- Bissau, Nepal, Peru Reduced provision of free-of-charge services Absenteeism and shirking by public sector health workers Illegal charges in public facilities Introduce top-down regulation limiting health workers’ dual practice Inform public patients about fees and charges, including free- of-charge services Separate public and private services Rising incomes and ability to pay for health services Improved governance, regulatory and implementation capacity Incipient formal private sector clearly separated from the public sector Dual practice to some extent regulated, and present outside and beside and at times within public services, but not in its integrated form Cabo Verde, China, Mozambique, South Africa, Thailand Poor quality public services Diversion of public patients to private practices Public sector personnel disproportionally distributed in facilities or locations in which dual practice is possible Limited range of public health services Allow regulated dual practice outside and inside public facilities in specific places and times Monitor the implementation of regulation Offer exclusivity contracts Encourage self- regulation by professional bodies High-income Sophisticated health systems and regulatory capacity Established private sector Regulated dual practice, allowed outside, and in some instances, beside public services Australia, Canada, Italy, Portugal, Spain, United Kingdom Poor quality public services Diversion of public patients to private practices Public sector health workers move to the private sector Market-based or financial interventions Provide incentives for positive behaviour Regulation by professional bodies Provide incentives to the private sector when outsourcing services Establish contracts with private providers PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 19 20 Policy brief 2.3.3 Supporting and protecting health workers Financing the existing workforce is one of the best investments that can be made If HCWs are not supported, are burnt-out and overworked and feel undervalued, this is a failure on behalf of employers. It means that HCWs will not be able to perform optimally and may drop-out of the workforce entirely. Creating sustainable employment conditions in-line with the ILO’s Decent Work Agenda is a critical investment to improve retention and contribute to HCWF development (ILO, 1999). Competitive salaries and benefits packages, flexible working arrangements,professional development and career advancement opportunities are all important investments to improve retention. It is also vitally important to ensure safe working environments, where health workers can deliver services effectively. This includes ensuring safe staffing, access to proper equipment and supplies, adequate workplace facilities (e.g. for breaks), workplaces free from harassment and discrimination, and support for mental health and well-being. While emergencies can impact the mental health and well-being of the HCWF (see the companion policy brief Global Health Workforce responses to address the COVID-19 pandemic by Ziemann et al., 2023), as literature documenting the impact of the COVID- 19 pandemic has shown, organizational support can play a large role in mitigating this and improving worker retention and productivity. For example, during the COVID-19 pandemic, studies have found that perceived organizational support such as the supply of personal protective equipment (PPE), training and organizational communication regarding COVID-19 reduced fear and consequently psychological distress among the HCWF (Labrague and de Los Santos, 2020 De Kock et al., 2021). Women make up a disproportionately large proportion of the HCWF globally, estimated to be 67% of the total workforce (ranging from 63.8% of the sector in LMICs to 75.3% in high-income countries), and yet there is a substantial gender wage gap with women being paid 20% less on average than men (WHO & ILO, 2022). In fact it has been estimated that the gender wage gap in the health sector is greater than that in other sectors. Investing in making health care sector working conditions safer for women, closing the gender pay gap, and providing decent working conditions for women with opportunities to enhance leadership roles will be fundamental to building a sustainable HCWF. 2.3.4 Managing performance Managing staff performance is a critical human resource function that is a prerequisite of good quality health care (Healy & McKee, 2002). Performance management can be defined as “an interrelated set of policies and practices that, put together, enable the monitoring and enhancement of staff performance” (Martinez & Martineau, 2001). Improved performance management can be achieved by investing in continuing professional development (CPD) (encompassing internal and external peer review, recertification and external assessment), and providing incentives and resources for changing performance (encompassing changing management strategies, information provision, support and peer group influence, and both financial and non-financial incentives). However, success usually relies on combinations or “bundles” of interventions rather than a single one. Table 2. Continuing medical education compared with continuing professional development as paradigms Source: Filipe et al. (2017). Characteristics Continuing medical education Continuing professional development Competency-based continuing professional development Drivers Teacher Self-directed Self-directed; needs of health care system Focus Clinical expertise All competencies required by medical practitioner Performance of medical practitioner in clinical practice Curriculum No Yes Yes Delivery Formal lectures in auditoria Wide range of learning methods; including online and informal, Wide range of learning methods; including online Outcome Improved patient care Improved patient outcomes Improved patient outcomes; meets needs of health care Comment Decontextualized, fragmented Self-assessment and reflection are assumed Performance in practice is measured objectively PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 20 21 What steps can improve and promote investment in the health and care workforce? Continuing professional development can be used to improve individual and team performance and help HCWs keep up with emerging and evolving practice Filipe, Mack & Golnik (2017) have suggested that CPD is a paradigm replacing that of continuing (medical or other professional) education (Table 2). CPD uses a broad range of methods and focuses on a broad range of professional attributes. It relies on self-direction on the part of the health professionals, but also oversight and direction from other health sector actors such as regulatory bodies. The endemic shortage of HCWs poses a serious impediment both in terms of health workers being able to leave their facilities for CPD, or use newly acquired skills. Workers in rural areas suffer the most due to transport challenges as well as lack of Internet to access online CPD in Tanzania, Malawi and South Africa (Feldacker et al., 2017). Similar results have been found in Philippines, where remote health staff have faced difficulties accessing courses that are mainly offered by private companies in cities; and there have been accusations of exploitation due to the high fees charged (Crispino & Rocha, 2021). This has led to exemptions from CPD. During COVID-19 disruptions in 2020–2021, many CPD opportunities migrated to online delivery allowing for some alleviation of these constraints. Some evaluations also identify lack of self-motivation (Feldacker et al., 2017), or demotivation due to different standards between health facilities in the context of lacking national requirements (Shah et al., 2016). There is very little literature about change management processes and techniques, likely due to a failure to publish rather than a lack of experience Shaw (2006) emphasizes a range of ways of supporting the human resource contribution to quality improvement. Such documented and published accounts of the use of mechanisms such as internal and external peer review and change management processes are scarce in the literature. This might reflect a failure to write up and publish experience rather than a lack of experience. Rowe et al. (2018) reviewed effective strategies for improving performance of HCWs in LMICs. They found 2 269 studies from 64 countries, exploring 118 strategies, most with multiple interventions. Strategies fell into the broad categories of community education, patient education, infrastructure strengthening, group problem solving, supervision, training, direct financial incentives, regulation and governance, printed information or job aids, ICT and other management techniques. Very little was reported on management techniques, and the review found almost zero effect size for some strategies such as job aids and printed information, and moderate effect sizes for strategies such as training or supervision when used alone. Their effect sizes were higher when combined. Group problem solving had the largest effect size as did community education when combined with health worker training. However, the quality of evidence of most studies was determined to be low and the differences in context and methods made cross-comparisons difficult. Financial incentives to improve performance are difficult to implement in settings where health systems are underperforming, may not be cost-effective or achieve desired outcomes. Much more has been published about the use of financial incentives to improve performance. Financial incentives arise from the ways health professionals are paid for their work in general – for example whether they are paid by salary, by fee for service or by capitation (Table 3). Given that no system dominates in terms of its characteristics, many countries have adopted blended systems, often with additional pay-for-performance (PFP) components. OECD country experience suggests that activity-based funding and PFP for hospital reimbursement are complex interventions that require a set of prerequisites including organizational commitment, adequate infrastructure, human, financial and information technology resources, change champions and personal commitment to quality care (Baxter et al., 2015). Experience from Thailand Table 3. Payment systems to improve performance Source: Olsen, 2017. Fee for service Capitation Salary Behavioural response Increase provision of services to all patients Keep all patients satisfied (but not necessarily the time consuming ones) "The patient in front of me shall be my only consideration" Negative effects Overprovision of own services Supplier-induced demand (SID) Underprovision of own services Cream skimming Cost-inefficiency (“shirking”, “slacking”) Waiting time Cost control within primary Bad Good Very good Gatekeeping Good Bad Good PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 21 22 Policy brief echoes this list of preconditions (Khampang et al., 2016) and experience from China highlights that PFP schemes require substantial institutional capacity and IT systems (Pu et al., 2020). Overall, the cost–effectiveness of PFP approaches is further questioned by reviews that suggest that their performance is mixed and where positive the impact is small (Lagarde, Huicho & Papanicolas, 2019; Borghi et al., 2015; Khan et al., 2019). 3. How can we ensure sufficient funding is available for strategic investments in the HCWF? During COVID-19, many countries and international organizations mobilized substantial additional funding to ensure the HCWF could respond to emergency demands and continue essential and elective services. However, there is now a danger that funding for the HCWF will be scaled- back as countries aim to restrict growth in public spending due to the economic fallout from the pandemic. This risks repeating mistakes of the past. As noted by the Pan- European Commission on Health and Sustainable Development, sustained underfunding in the HCWF in Europe – often in response to austerity agendas implemented in the aftermath of the economic crisis in 2008/9 – left health care systems in Europe less resilient and less able to respond to COVID-19 (McKee, 2021). Even with challenging economic circumstances, it is vital that existing funding is protected and additional resources mobilized to help countries reform and strengthen their HCWF. This will require ambition at both the national and international levels and stronger collaborations to plan, prioritize and focus investments where they are most needed. A new approach and a new narrative is needed to ensure financing for the HCWF is not seen as a short-term cost, but rather a strategic long-term investment that can enhance the resilience of health care systems, societies and economies. This section explores how sufficient resources for the HCWF can be made available from domestic and external sources. 3.1 Protecting and increasing public revenues at the national level 3.1.1 Creating fiscal space for public revenues Specific to the HRH, the creation of fiscal space is the ability “to direct resources towards health workforce investments without unduly compromising the short-to-medium term ability of the government in other functions—substantially crowding out expenditure in other areas of the health sector or other sectors” (Asamani et al., 2022). Common sources of fiscal space for health are outlined in Box 5. Box 5. There are a number of well-known mechanisms to create fiscal space for health There are a number of common options for government to raise revenues for health, with most countries using a mix of options: Promoting economic growth: If the economy grows and the proportion of fiscal revenue allocated to health remains constant, the result is more fiscal space for health (Tandon & Cashin, 2010). The structure of the tax and the health financing system may influence how economic growth translates to increased fiscal space for health. For example, if economic growth results in increased wages, and the health system is primarily funded through an earmarked payroll tax, this would result in a substantial addition to fiscal space for health. On the other hand, the same economic growth would have less of an impact on a system where health is primarily funded from general taxation (PAHO, 2020). PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 22 23 What steps can improve and promote investment in the health and care workforce? Increased and more efficient domestic revenue collection: Greater taxation and more efficient tax collection are important components to increase fiscal space for health (PAHO, 2020). This may include through VAT; taxing income,assets, multinational companies or industries; earmarked taxes; and so-called sin taxes on items that adversely affect health (usually tobacco or alcohol). Some indirect taxes such VAT and sin taxes are regressive in nature; however, they can play an important role in raising revenues in countries with large informal economies that may take time to build up a sufficient tax base. Policies that increase tax efficiency, for instance by allowing fewer tax exemptions or better tax administration, also help to raise revenue for health. Prioritizing spending on health and HRH: Reprioritizing funds towards health is defined as increasing the proportion of government budget allocated to the health sector. The potential to expand fiscal space for health through reprioritization is considerable, with few countries spending the recommended 5% proportion of the government budget on health (WHO Global Health Observatory, 2022; Barroy, Sparkes & Dale, 2016). Redistributing expenditure towards health has several challenges. Public expenditure is often already committed either legally, contractually or politically and cannot be repurposed without undesirable consequences. Also, redistributing expenditure often requires delicate trade-offs between expenditure in other sectors and consideration of wider economic consequences Improving the efficiency of spending: This can be achieved, for example, by reforming: pharmaceutical policies on procurement, distribution, pricing and reimbursement; provider payment systems; HRH policies and management practices; public financial management reforms. Borrowing can provide governments with additional resources in the short-to-medium term, but may ultimately constrain resources as interest payments and loans are repaid. External overseas development assistance may be necessary for some countries, but should not be thought of as a long-term solution due to the volatility of funding, displacement of domestic funding and absorptive capacity challenges. Some countries face internally and externally imposed constraints that limit their ability to create fiscal space Public sector domestic financing is the most important source of funding for the HCWF, both in the short and long- term. Raising additional domestic resources for HRH will be enormously challenging given the deterioration in public finances and increasing levels of debt due to the economic downturn from the COVID-19 pandemic, in particular in LMICs. Creating fiscal space and raising additional domestic revenues for investment in the HCWF is, however, possible for all countries even though support from external sources of funds may also be needed to fund all required reforms. The WHO Council on the Economics of Health for All (2021) nevertheless highlights that many countries, particularly those in the global south, face constraints on their monetary sovereignty that limit their ability to create fiscal space for health. These constraints include: 1. internally imposed legal limits on the levels of budget deficits, national debt or government expenditure; 2. externally imposed fiscal rules, in the form of austerity recommended or required by supranational groups, such as the European Union (EU), or by international financial institutions such as the International Monetary Fund (IMF), which have historically required governments to limit the size of their budgets or meet debt reduction targets in exchange for financial assistance in the event of an economic, financial or social crisis; 3. concern about the impact on credit rating and ability to access capital. Capital market players tend to have exaggerated concerns with sovereign debt viability, to the extent that even modest increases in fiscal deficits or national debt can lead to sell-offs of government bonds and national currencies; 4. the difficulty of raising tax revenues consistently in proportion to economic activity, owing to low corporate tax rates and corporate tax incentives, reliance on regressive value added taxes, tax avoidance by multinational corporations and high net-worth individuals, and trade and investment treaties that compromise public capacities to raise tax revenue. A rethink of internally and externally imposed limitations on public spending by governments and multilateral organizations could help create additional options for countries to raise public revenues and invest in public services such as health. 3.1.2 Political leadership and intersectoral collaboration Strong political leadership is a fundamental condition for increased investment in the health and care workforce There will be no efficient investment in the HCWF without strong political leadership to prioritize and champion additional funding. This precondition was exemplified during the COVID-19 pandemic, with the mobilization of substantial resource for the HCWF only possible once it became a political priority and top-level government officials agreed upon additional investments (Box 6). Box 6. Ghana Investment in the HCWF during the COVID-19 pandemic In response to the COVID-19 pandemic, the Government of Ghana (GoG) announced a strategy to rapidly recruit qualified but unemployed health workers to fill staffing gaps and incentivize all public sector health workers by waiving income taxes on their salaries. To holistically improve the country’s health systems performance and resilience, Ghana significantly increased its public sector health workforce (HWF) capacity by recruiting 45 107 new health workers between April and November 2020. Of these new recruits, 44 107 were permanent staff of various categories (including health professionals and graduate unemployed nurses and midwives) and 1 000 were temporary contact tracers. To incentivize the health workforce, the government waived personal income taxes for all public sector health workers from April to December 2020 and offered 10 001 front-line health workers an additional 50% allowance. The government also committed to paying a 50% base salary bonus to front-line health workers and ensured their protection by providing PPE, training on infection prevention and control, and life insurance cover of up to GHS350 000 (approximately US$ 60 345) per front-line health worker against COVID-19 infection and death. PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 23 24 Policy brief Conservatively, Ghana spent at least US$ 213.6 million on health workforce recruitment and incentives during the first year of the pandemic. The new recruitments are estimated to have increased the health sector wage bill by 32% compared with that of 2019; 47% of the sector budget came from GoG sources, while the remaining 53% was sourced from internally generated funds of health facilities (24%) and from development partners and donors (29%). The GoG’s significant investments in the health workforce during the pandemic resulted in a 35.5% increase in public sector health workforce capacity. This not only helped to mitigate the impact of the pandemic on the country’s health workforce but also provided public sector employment opportunities for health workers who would have otherwise remained unemployed. Additionally, incentives provided to health workers played an essential part in mobilizing the health workforce for emergency response. Source: Asamani et al., 2022 Intersectoral stakeholder engagement is needed to plan and co-finance strategic investments Improved intersectoral governance processes are needed to bring together public, private and other stakeholders to plan and co-finance HRH investment plans. This is especially so as much of the funding to strengthen the HCWF falls under the remit of the education sector. Successful intersectoral leadership happens if the Ministry of Health and another ministry, such as education, employment or finance, agree on the importance of investing in the HCWF and, at the same time deem the focus of the investment uncontroversial, which may include expanding, strengthening and innovating training programmes and facilities, and improving working conditions. Where the importance of an investment is agreed upon, intersectoral collaboration will be relatively easy (Greer, 2012). Some of it will be purely technical and the political part may relate to the distribution of investment costs, and the credit for the successful collaboration, to bring the health system and UHC forward. Very often, however, different sectors assign different priorities to investing in the HCWF. While other sectors may pay lip service to the importance of HCWF development, they will argue that they have more important priorities. Or they may not agree on the focus on investment. Traditionally, medical schools and ministries of education would argue for more specialist training to achieve clinical excellence, while ministries of health are trying to increase the number of general practitioners, nurses and nurse practitioners. All too often the proposal of the Ministry of Health to invest in the HCWF is controversial as the treasury or Ministry of Finance may argue for budget consolidation or austerity policies. For example, in Ireland during the economic and financial crisis, the Ministry of Health avoided substantial cuts in the front-line HCWF but had to introduce staff reduction in non-acute settings (Williams & Thomas, 2017). In 2015, nursing bursaries in the UK were cut under an austerity agenda, leading to a massive drop in student applications. The bursaries were reintroduced in 2020 but with a substantially lower endowment (Foster, 2017). Top-level leadership, however, is a necessary precondition for successful governance if there is no consensus between the health sector, education, employment and finance. It is then up to the head of state to make it a top priority and to mobilize the cabinet and set the HCWF agenda. The COVID- 19 priority has provided plenty of examples for top-level leadership, when decisions on investing in health systems and the health workforce were at the discretion of the head of state. There were in many countries several waves of time-limited centralization of health system and HCWF decision-making (Greer et al., 2022). A whole-of-government approach may also be necessary because in many countries key functions are delegated to arms-length bodies such as health service executives or self- governing bodies such as sickness-funds. In those cases leadership and agenda setting may need to be accompanied by specifying legal mandates. A whole-of-society approach is key because the health system is populated with many civil society organizations and some of them are the most powerful in a country. Medical chambers, professional associations, associations of providers and patient organizations may support, or prevent or divert investment in the HCWF. The power of vested interest must not be underestimated. They may divert monies into the wrong pockets, contributing to inefficient investment. An example of the potential of intersectoral dialogue to facilitate greater investment in the HCWF can be seen in Niger. Here, the ILO-OECD-WHO (International Labour Organization-Organisation for Economic Cooperation and Development-WHO) Working for Health (W4H) programme enabled Niger to engage with a range of sectors and ministries to develop a National Action Plan for Investment in Health and Social Sector Employment and Growth 2018– 2021. The Plan was endorsed by the government and adopted through a presidential decree. In 2019, the programme led to the creation of 2 500 community-based health worker jobs and 5 000 indirect jobs in three regions (UHC2030, 2020). HRH units in ministries of health are needed to help plan and provide evidence for HCWF investments To facilitate coherence across sectors, particularly health and education, Human Resources for Health Units have been recommended to be set up to coordinate inter- and intra- ministerial action to support HRH strategy (Cometto et al., 2019). As part of the monitoring of the implementation of that policy, WHO (WHO Regional Office for South-East Asia, 2018a) reported that of 11 countries surveyed, eight had set up such a unit by 2018 while two of the others had developed other institutional mechanisms to serve the same purpose. Further ways to strengthen intersectoral cooperation and planning for the HCWF are discussed in greater detail in the companion policy brief What can intersectoral governance do to strengthen the health and care workforce? by Caffrey et al., 2023. It is important that ministries of health are at the decision- making table when financial decisions are made. For example, HCWF salaries which make up the major PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 24 25 What steps can improve and promote investment in the health and care workforce? proportion of health budgets in many countries and play a critical role in attracting and retaining health workers, are often outside of Ministry of Health control as pay scales are determined by civil service rules which might be inflexible. Investment decisions in HCWF need to be guided by timely strategic analysis of population health needs, education supply and labour markets. For this, robust health information systems are required which can provide disaggregated data such as by gender and different types of health professionals. The governance of private investment and public– private partnerships need to be strengthened There is no adequate replacement for publicly funded health care and public investment in the HCWF. At the same time, it should be acknowledged that private sector for-profit and not-for-profit financing plays a key role in funding health care globally. This type of financing nevertheless brings many challenges as private firms are often looking to maximize profits in the short-to-medium term which may run counter to longer-term health sector goals (WHO, 2021c). Moreover, public–private partnerships can increase the overall cost of projects to the government if not properly managed and monitored. This makes it important that governance of private financing and the design of public– private partnerships are strengthened to ensure they align with public sector aims. As noted by the WHO Council on the Economics of Health for All (2021), this may necessitate better regulation, improved transparency and accountability in decision-making, as well as “redesigning the terms and conditionalities that structure contracts, grants, transfers, loans and partnerships”. In addition, incentives such as through explicit and implicit subsidies can be offered to encourage private investment to align with health sector goals. 3.1.3 Making the economic case for investing in the HCWF The health sector needs to generate quantifiable evidence on how the HCWF contributes to health system, economic and societal goals There is often pervasive underinvestment in health and social policies and the public sector as a whole. This is especially so in highly “feminized” sectors such as health that employ large numbers of women who are often undervalued by policy-makers and society more widely (WHO & ILO, 2022). The health sector is also seen as highly labour-intensive and therefore unproductive, reducing desire from some actors to fund it sufficiently. There is therefore often little concerted discussion between connected ministries around financing for HRH and the “negotiating” space is limited. A new narrative is needed to ensure that the HCWF is seen as an investment and not a cost. Country-specific evidence to quantify and demonstrate how much investment in the HCWF contributes to meeting health, social and economic objectives can help provide evidence to generate political support for greater funding. For example, stable and sufficient funding for the HCWF can drive inclusive economic growth by creating jobs – especially for women, young people and in rural areas. WHO and ILO have calculated that the HCWF directly account for 3.4% of total global employment, ranging from 1% of total employment in LMICs and up to 10% in high-income countries (WHO & ILO, 2022). Investment in the HCWF can also help promote economic diversification, reducing dependence on industries such as tourism or extractive industries that are susceptible to changes in external markets and other shocks such as the COVID-19 pandemic (Lauer et al., 2017). The health sector also drives job creation and innovation in productive industries such as pharmaceuticals, research and development and manufacturing. While there is limited evidence on effects in LMICs, evidence from high-income countries suggest they are substantial. In Spain, for example, the health technology industry employed 28 500 people in 2020 and generated a turnover of €8.8 billion (Bernal- Delgado & Al Tayara, 2022). In France, digital health start-ups were estimated to have an annual turnover of €800 million in 2019, rising to a projected €40 billion by 2030, while the medical devices sector had a turnover of €30 billion in 2019 and generated 90 000 jobs (Or & Al Tayara, 2022). Investing in the HCWF can also generate substantial economic benefits by promoting health and human capital development, social cohesion, social protection and health security (Lauer et al., 2017; WHO, 2017). The health sector can therefore support progress in meeting a number of SDGs including: improved health and well-being (SDG 3), decent work and economic growth (SDG 8), poverty alleviation (SDG 1), improved education (SDG 4), gender equality (SDG 5) and reduced inequalities (SDG 10). It is enormously challenging to determine the overall contribution of the HCWF to the economy due to various multiplier effects. However, estimates of the size of the broader health economy, while still difficult to calculate, give some indication of the importance of the HCWF for economic growth. For example, using data from the OECD and World Bank, Lauer et al. (2017), have estimated that the size of the health economy in 34 OECD countries amounted to almost US$ 10.3 trillion prior to the COVID-19 pandemic; the global health economy was stated to likely be “the second-largest economy in the world, after … the United States”. It is therefore likely the returns on investment in the HCWF in terms of promoting inclusive economic growth are considerable in every country. Securing and mobilizing long-term sustained levels of domestic funding also requires evidence on the efficiencies that can be gained through existing expenditure on recurrent costs that may be underfunded, such as salaries, enhancing working environments and protection and support measures. Evidence on efficiency gains from recurrent spending is limited, and requires improved monitoring and evaluation in countries to show how investment is linked to different health system goals. This requires better data and stronger HRH information systems, as well as necessary institutional capacity in ministries of health. PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 25 26 Policy brief 3.1.4 Improving budget efficiency in the health sector Budget efficiency in the health sector is important to help prioritize and allocate funds better Inefficiencies in the health sector budget cycle processes – the prioritization and allocation of funds, the execution of the budget and its evaluation – has been identified as a key challenge to efficient investments in building a resilient health system in LMICs (Barroy et al., 2019). In many countries health budgets are disconnected from health sector needs and planning and costing processes relying on input-based or line-item budgeting using historic trends. There are additional issues in the expenditure of allocated funds due to several factors such as late release of health sector funds, rigidities in ex-ante accountability structures and controls, limited health provider financial autonomy and ability to reallocate funds according to needs. Weak public financial management (PFM) systems in the health sector have led to endemic underspending of health budgets in LMICs which leads to a vicious cycle of reduced funding in subsequent years (UHC2030, 2020). Barroy et al. (2019) estimated that 13 of 26 African countries reported more than 15% of underspending of their annual health budgets. Budget efficiency in the health sector can be achieved through a number of mechanisms with the specific approach dependent on country context and the specific challenges faced by the health system (Box 7). Box 7. Budget efficiency in the health sector can be improved through a number of actions Evidence-based decision-making: Allocating resources based on the best available evidence of what works, such as clinical and cost– effectiveness studies, can help ensure that resources are used effec- tively and efficiently. Strategic purchasing: Health systems can leverage their purchasing power to negotiate better prices for essential health products and services. Increased transparency and accountability to help prevent corruption and mismanagement of health funds, and provide a more accurate picture of where resources are being used. Improved financial management: Strengthening financial man- agement systems and processes, such as budget planning and fore- casting, can help ensure that resources are used effectively and efficiently. Better health workforce planning and management: Effective planning and management of the health workforce can help reduce the costs associated with staff turnover and absenteeism, and can also help ensure that the right skills and resources are in place to deliver quality care. Health systems strengthening: Addressing broader systemic is- sues, such as weak governance and weak health systems, can help ensure that resources are used effectively and efficiently, and that health outcomes are improved. Some lessons have emerged from COVID-19 on PFM mechanisms that made it easier for countries to quickly respond to the pandemic or caused barriers to an effective response (Barroy H et al., 2020). COVID-19 responses showed that countries with a flexible programme-based budget structure linked to policy objectives and outputs rather than line-item budgets made it easier to quickly reallocate funds. It is important that these structures are paired with robust accountability mechanisms to improve expenditure tracking. Further robust intergovernment transfer mechanisms built on formula-based approaches were key to moving money to the frontlines quickly. While some countries with more robust mechanisms built on these in their PFM response to COVID-19, others with weaker PFM systems introduced changes to their regular systems to allocate and disburse funds in an emergency. Countries should explore how they can sustain these changes to help respond more efficiently to HCWF investments for the future. While countries have been putting in place policies and systems to reform their public management systems, this is not an easy task and will take time. 3.2 Rethinking external sources of funding to support HRH goals Solidarity and cooperation at the multilateral, regional and domestic levels is needed to secure sufficient and sustained investment Domestic resource mobilization is key to funding the HCWF. However, creating sufficient fiscal space to meet HCW targets is likely to be challenging for countries with constrained budgetary space, especially low-income countries. External source of funds, such as through regional funding initiatives, direct financing and foreign aid can play a critical role in mobilizing sufficient resources to meet health-sector specific goals. This is especially so as rising levels of debt and fiscal deficit and a fall in remittances curtails the ability of many countries to raise sufficient domestic revenues to fund the health sector and other public services. 3.2.1 Regional funding initiatives for the HCWF Regional funding initiatives play an important role in providing additional investment for the HCWF All regions have established their own collaborative funding mechanism, which provide some funding for HCWF employment and education initiatives as part of broader social and economic development programmes. For example, the EU has numerous mechanisms available that can be used by Member States in support of HCWF objectives, with the amount of funding available increasing since COVID-19 (Box 8). Another example is the Inter- American Development Bank (IADB), funded through Member countries’ subscriptions and contributions, borrowings from capital markets, equity and co-financing ventures, which provides loans, grants, guarantees and equity investments to Member countries (IADB, 2023). Part of the long-term socioeconomic development funding available can be used to support national objectives for the HCWF, such as developing rural health posts, ensuring the optimal utilization of HRH at the hospital level, and investment in education and training – including infrastructure. These types of regional cooperation mechanisms that pool resources and capacities can help fund education and employment initiatives that would otherwise be cost prohibitive to establish using national financing. PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 26 27 What steps can improve and promote investment in the health and care workforce? Box 8. The EU has a number of financing mechanisms available to Member States and third countries for HCWF reforms Although the organization and delivery of health care, including health workforce planning, is an EU Member State competence, in- vestment in the retainment, development and training of HCWs is supported through a range of financial instruments at Union-level. The COVID-19 pandemic has unlocked new funding through the Re- covery and Resilience Facility (total budget: €723.8 billion in grants and loans) with a focus on promoting the green and digital transi- tions, which some Member States have opted to partly invest in training, upskilling and capacity-building in these areas (European Commission, 2021; 2023a). This can be complemented by support from other large financial packages, including the Cohesion Policy funds, which finance a broad range of training, education, employ- ment, and social initiatives through the European Social Fund Plus (ESF+ €99.3 billion). The EU also contributes to monitoring and developing solutions to tackle workforce challenges, having funded several multi-country projects and joint actions in recent years through its Health Programme (now EU4Health), including the “health workforce pro- jects cluster”, covering five different projects focused on task-shift- ing, retention, and medical deserts (European Commission, 2021c; 2023b; AHEAD, 2023). With a budget over 10 times larger than its predecessor (MFF 2021–2027: €5.3 billion), EU4Health is likely to continue offering similar funding opportunities through a dedicated work strand on health systems and the health care workforce. The EU also invests in the professional development of HCWs beyond the Union’s borders (WHO, 2010). For instance, Horizon Europe (e.g., Marie Sklodowska-Curie Actions for doctoral and postdoctoral train- ing) or Erasmus+ (2021–2027 MFF: €26.2 billion) are primarily EU- based but offer some training and professional development opportunities that are accessible to individuals (and institutions) from third countries (European Commission, n.d.). Global Europe, the EU’s umbrella instrument brings previously separate funds under one roof to support its neighbourhood, international cooperation and devel- opment policies in third countries. With a total budget of €79.5 bil- lion (2021–2027 MFF) and earmarked funding for human capital development, supporting health workforce skill-building, training and recruitment is featured among its investment priorities. Fig. 5 The United States has generally been the largest funder of development assistance for HRH, but contributions from other countries and Foundations are growing Source: Micah et al., 2022. 0 1 000 2 000 3 000 4 000 2000 2005 2010 2015 2020 U S$ m ill io n Unallocable Other sources Debt repayments Other private philantrophy Bill & Melinda Gates Foundation Other governments Australia Canada China Japan Norway United Kingdom United States PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 27 28 Policy brief 3.2.2 Multilateral and bilateral funding for the HCWF The share of development assistance spent on the HCWF has increased over time but remains low and needs to be increased Tracking of development assistance for the health workforce over time shows it has increased since 2016 (Micah et al., 2022). In 2020, development assistance for the health workforce reached a high of US$ 4.09 billion; this is more than two times the amount in 2016, the year the WHO’s Global Strategy on Human Resources for Health was adopted (Micah et al., 2022). Approximately 30% of development assistance for HRH activities was allocated to 47 countries identified by WHO as having the most pressing UHC-related HRH needs. However, Micah and colleagues highlight that development assistance for the health workforce comprises a small proportion of total development assistance, at a share of just over 5% per year since 2016. Moreover, while the growth rate in development assistance for HRH was positive in all regions from 2000 to 2015, the year-on-year growth rate between 2016 to 2020 was negative in North Africa and the Middle East, South Asia and sub-Saharan Africa. The United States has been the largest individual donor to health workforce related activities since the mid-2000s (Fig. 5). However, contributions from the Bill & Melinda Gates Foundation and from other governments, notably China, Japan, Norway and the United Kingdom, have increased substantially over time (Micah et al., 2022). From 2016 to 2019, the largest share of development assistance for the HCWF has been allocated to training (42.4%), followed by activities that support the creation of HRH policies and management plans (27.6%), 17.5% allocated to other activities not classified, education (5.3%), staffing costs (4.1%), infrastructure (3.2%) and a negligible amount for health workforce information systems (Micah et al., 2022). As noted by Micah et al., funding skewed towards training can help alleviate immediate skills gaps; however, it may not promote development of a sustainable health workforce as it does not tackle major issues such as the high costs of educating and employing HCWs or managing internal and international mobility. Additionally, under a third of development assistance for the HCWF during this period was targeted towards activities designed to promote gender equality. This is despite women comprising the majority of the HCWF globally and the existence of persistent gender-based inequalities in pay (WHO & ILO, 2022). Global health financing should support long-term objectives and facilitate additional and sustained increases in domestic resourcing for the HCWF A substantial increase in external source of funding will likely be necessary to help many countries reach HCWF-related goals. For example, even prior to COVID-19, Stenberg et al. (2017) estimated that an additional US$ 92 billion to US$ 150 billion would be needed annually to help strengthen the HCWF in LMICs. Initiatives that use blended financing models that combine different sources of funding, such as grants, loans and private sector investments, are likely to become increasingly important in raising additional revenue for the HCWF from international sources. The goal of such initiatives is to leverage different sources of capital to bridge financing gaps and maximize the impact of investments. In blended financing initiatives, concessional loans are offered on terms more attractive than market conditions, helping to de-risk investment for countries and private capital. One example of a blended financing approach is the Lives and Livelihoods Fund launched by the Islamic Development Bank in 2016, and supported by the Islamic Solidarity Fund for Development, the Bill & Melinda Gates Foundation, the King Salman Humanitarian Aid and Relief Centre, the Qatar Fund for Development, the Abu Dhabi Fund for Development, and the UK Department for International Development. The Fund pools grants from donors together with ordinary (market-based) lending capital from the Islamic Development Bank, allowing concessional loans to be given to low-income Member countries to support essential development projects (LLF, nd). The Fund has supported projects to support education and sustainable employment of HCWs, including in Benin (Box 9). Box 9. Concessional financing in Benin to improve access to services and progress towards UHC A situational analysis undertaken by the Ministry of Health in Benin in 2016 identified a shortage of health workers and uneven distribution of staff across provinces. The Government of Benin made addressing these HCWF issues a central pillar of health reforms in the country to con- tribute to the achievement of the objectives of the National Plan for Economic and Social Development (PNDS). A Committee was established in the Ministry of Health with representa- tion from various units (e.g. HRH, nutrition and Overseas Development Assistance (ODA)) to develop and cost an investment plan for reforms. The Government took the lead in negotiating co-financing with the Is- lamic Development Bank, with the Global Fund supporting develop- ment of a project plan to ensure all HRH components were in place. Funding through the Lives and Livelihoods Fund package was agreed in April 2021, for a 5-year programme. The project aims to make health services permanently accessible to the entire population through strengthening community health services, ensuring quality in HRH and nutrition services; and to strengthen the epidemic and infectious dis- ease prevention system through the organization of epidemiological surveillance from the community level, research and adaptive manage- ment. Total project funding amounts to $52.8 million, with $22.4 mil- lion (42.4% of funding) allocated specifically to the HCWF component. Total funding comprises $32.5 million IDB loan (61.6%), complemen- tary grant from the LLF committee (from donors) of $17.5 million (33.1%) and Government of Benin funding of $2.8 million (5.3%). Expected project results related to the HCWF include the recruitment, training and deployment of 400 medical doctors, 400 nurses and midwives, and 600 health assistants in rural areas to provide health and nutrition services to communities, and the recruitment and de- ployment of 4 157 community health workers in their communities to provide home-based health and nutrition services. The project aims to ensure sustainability in recruitment through pub- lic–private partnerships. For example, at the end of their 2-year con- tract through the project, GPs can set up a private practice in a location where need arises to bring quality care closer to the popula- tions; continue training to become a specialist in an area deemed a priority by the Ministry to reduce long-term shortages; or become a civil servant. This will be financed through a savings plan, where monthly transfers of a specified amount are made to a dedicated in- dividual savings account for the duration of the 2-year contract which are made available to fund the chosen exit option. This mecha- nism means that the overall number of civil servants in the country will not go above an agreed upon ceiling in the country. PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 28 29 What steps can improve and promote investment in the health and care workforce? Development assistance should reflect country priorities and help support longer-term HRH objectives. This includes funding for areas such as better remuneration, development of HRH information systems and management capabilities, and improving infrastructure for service delivery, among others. To achieve this, it is important that countries are able to identify their short and long-term HCWF needs to prioritize spending. Donors meanwhile should aim to improve engagement with each other and with countries to strategize and plan HCWF investments (Micah et al., 2022). An honest and rigorous assessment of the impact of external sources of funding, including the conditions tied to loans, would help identify and reform how international sources of funding are used to ensure it better contributes to improving the long-term resilience of the global HCWF. A number of innovative ways to increase direct financing and monetary reserves of countries have been suggested and could be championed by health sector actors In acknowledgement of the challenge with global health financing, the G20 High Level Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response has recommended the establishment of a new multilateral financing mechanism (Okonjo-Iweala, Shanmugaratnam & Summers, 2021). One suggestion is for this mechanism to be hosted by the World Bank and take the form of an intermediary fund. The aim would be to raise an additional (above existing financing) $10 billion a year from the international actors community – two thirds of the estimated additional international financing needed to improve emergency preparedness and response and strengthen global health security (Okonjo-Iweala, Shanmugaratnam & Summers, 2021). In addition, the WHO Council on the Economics of Health for All (2021) identified more extensive debt cancellation, and the issuing of more SDRs (Special Drawing Rights) by the IMF, as potential options that could enable countries to raise additional resources to spend on health without squeezing funding on other public services. Other actions to raise direct financing, include reforming international corporate taxation – such as by reducing tax avoidance and giving national governments some right to tax the profits of multinational companies – and changing sovereign credit ratings to consider investment in health as a way to increase economic resilience and reduce credit risk (WHO Council on the Economics of Health for All, 2021). Implementation and agreement on these options are of course outside the control of health sector actors and do not by themselves guarantee that more funding for the HCWF will be made available. Global and national-level health stakeholders need to make the “international” case for these radical solutions and for increased investment in the HCWF. Bold measures are needed to enable countries to raise resources to spend on health and to tackle the looming HCWF crisis, and health ministries must advocate courageously. 4. Conclusions and policy considerations for the future Without the right people and infrastructure, it is not possible for health systems to deliver high-quality and efficient care that is responsive to population health needs. With COVID- 19 unlikely to be the last pandemic, especially with threats from climate change growing, it is essential that political leaders at the country, regional and international levels step up and work together to ensure the HCWF is adequately funded. This is not simply a case of protecting and increasing investment, it is ensuring a proper approach to funding by investing in actions that drive efficiency, and can secure additional capital and operational investment to expand capacity of the health system to meet population needs. Even as economic growth slows, education, employment and retention of HCWs needs to be a priority in public expenditure to increase supply, protect the existing workforce and plan ahead to address future challenges. The paper has covered a wide array of discussion in relation to the development of human resources and much of it is more relevant to the long-term health system development and HRH planning objectives than resolving immediate crises that countries might be facing. It is critically important to be clear about long-term directions and objectives in deciding on short-term measures. Investing in education supports the HCWF, creates human capital and enables innovation Societies need to invest in the right HCWF education and training to enable health systems to meet population health needs. In the short run, maintaining the effective functioning of existing public training infrastructure, retaining faculty and supporting engagement with interprofessional education will help steer countries towards an interprofessional training curriculum. Online learning tools represent a cost-effective way to improve access to education, especially in rural areas. In the long run, investing upstream in secondary education and in science and technology skills can help provide candidates for the HCWF and create human capital. Countries should also focus on opportunities to manage a gradual expansion of training to meet local needs with the right balance of health professions. Gradual expansion allows the growth of training school faculty membership in size and preparedness for the evolving health system both with respect to its team led nature, and the disease burden characteristics post epidemiological transition. It will also ensure that opportunities for placements in which the most important clinical skills can be developed can be enhanced in parallel. The management of gradual expansion can also accommodate realistic increasing financial availabilities. Financing of education has to ensure the oversupply of HCWs to account for attrition to replenish stock. However, this will be a stimulant for human capital and skills development in all countries, irrespective of whether they end up in the health economy. PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 29 30 Policy brief Investing in training for the primary care HCWF and in developing the right people to fill gaps in underserved and hard-to-reach areas can achieve efficient service delivery Meeting population health needs and progressing towards UHC requires investment to better target who to educate and train. In relation to long-term directions, the paper suggests the importance of sustaining the implementation of measures to build the primary care system towards a team approach supported by interprofessional education in health workforce formation and using continued professional development according with national standards that reinforces the team as the principal unit of activity. Countries already on this path should look at further developing the mix of clinicians making up PCTs and moving towards specifying the set of non-clinical staff members needed in extended care teams. Developing mid-level cadres instead of just high-level cadres is likely to be less expensive and a more efficient way to meet population health needs. The discussion on the right skill mix and composition of the HCWF is not new (Maier, 2022). With increasingly ageing populations in many parts of the world and the rise of noncommunicable diseases, health workers with a different mix of skills will be required to support people with chronic conditions and healthy ageing (WHO, 2016b). The COVID-19 pandemic once again highlighted how a resilient health system required different skills – both clinical and non-clinical – to manage the pandemic and deliver high-quality services more generally (van Stralen, Carvallo & Girardi, 2022; Winkelmann et al., 2022). This includes having a HCWF with the necessary competencies to make use of digital technologies, which hold enormous potential to increase the efficiency and quality of health care services. Creating a more flexible health workforce in the future will require consideration of the laws regulating current scopes of practice of different cadres and how these can be made more flexible (van Stralen, Carvallo & Girardi, 2022) (see the companion policy brief Global Health Workforce responses to address the COVID-19 pandemic by Ziemann et al., 2023). Investing in the right people and incentives can fill gaps in underserved and hard-to-reach areas In developing the strategy for the long-term future health workforce, it will be important to use the tools of market management rather than central planning. Instead of posting professionals to locations of need in rural and other underserved areas, such roles need to be made attractive to those whose preferences are most aligned in order to overcome shortages. This is not all about increasing salary, though adequate salary levels will always be important. Job characteristics can also be shaped to attract graduates in ways that reduce the need for salaries to compensate for their absence. This includes improving working environments, ensuring that family life is supported with housing, transport and schooling and ensuring that career opportunities are enhanced rather than constrained by accepting such postings. The development of rural based professional training schools and the recruitment of students from rural origins will all help to support successful market management. Market management approaches will also be required to manage the public–private mix in countries with mixed health systems, recognizing that public sector roles compete with private sector roles for the limited health professional staff available. This applies to recruiting staff to positions and retaining their working time in public sector roles by limiting the impact of dual practice on their availability for those roles. Investment in HCWF education will be wasted if HCWs are not able to find employment or are not protected and leave the sector In some countries – especially LMICs – insufficient public investment has led to underemployment or unemployment of available HCWs. Greater investment in labour market policies is therefore needed to stimulate employment opportunities for the HCWF, with a special focus on women and youth. Producing sufficient graduates is not enough, they need to be able to find employment within the health sector, and stay in health careers. Coordinated investments – both domestic and international – and across multiple sectors such as education, health, labour and trade, are needed to stimulate the health labour markets and HCW employment. Urgent investment is also needed to retain existing HCWs, such as by ensuring fair pay and decent working conditions, protecting and supporting health workers and helping them perform to their potential. Managing performance also has a key role in motivating and retaining staff, and can be promoted through CPD and a mix of other incentives. All countries can learn much from the range of COVID-19 responses for mechanisms to increase the availability of health staff, maintain them in priority roles and reduce attrition, and to upgrade skills where gaps are clear (see the companion policy brief Global Health Workforce responses to address the COVID-19 pandemic). Securing and mobilizing long-term sustained levels of domestic financing for recurrent HCWF costs relies on demonstrating efficiencies of spending on initiatives such as those to enhance working environments and promote decent work, that may otherwise remain underfunded. Investment in the right employment reforms can help address many fundamental challenges, such as high outward migration, maldistribution in rural and other underserved areas, and gender inequalities. Political leaders need to commit to investment in the HCWF to attract, retain and motivate HCWs to continue progress towards UHC and meeting SDGs Political leaders proved during COVID-19 that remarkable things are possible and that additional funding can be made available for the HCWF when it is a political priority. Only top-level political leadership can secure the financial commitment needed to produce the oversupply of HCWF to break the cycle of shortages and high attrition. Improved intersectoral governance processes are crucial in bringing together public, private and other stakeholders to plan and co-finance HRH investment plans (see the companion policy brief What can intersectoral governance do to strengthen the health and care workforce? by Caffrey et al., 2023). PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 30 31 What steps can improve and promote investment in the health and care workforce? This is especially as so much of the funding to strengthen the HCWF sits within the education sector. Human Resources for Health Units within ministries of health can help coordinate inter and intra-Ministerial action to support HRH strategy and to be at the decision-making table when finances are allocated. While challenging in the current economic climate, countries can create additional fiscal space for investments in HCWs in the future. The increased recognition during the pandemic – that the HCWF makes an invaluable contribution to the economy, decent employment, health security and societal well-being – needs to be used to convince finance ministries that the HCWF matters. This requires stronger monitoring and evaluation to enable countries to quantify how HCWF investment supports health, societal and economic outputs and attaining SDGs. Solidarity and cooperation at the multilateral, regional and domestic levels are needed to secure sufficient and sustained investment Development assistance and other forms of international financing are valuable in many circumstances to help secure funding for HCWF reforms. Nevertheless, countries and international donors need to make sure that it is used to support longer-term objectives for a more resilient and fit- for-purpose health workforce and not just to overcome short-term crises. When used to support long-term objectives, international sources of funds can facilitate additional and sustained increases in domestic resourcing that can be used for the recurrent cost of developing and maintaining the HCWF. Radical options may be needed to raise global health financing. These include more extensive debt cancellation; blended financing options; more IMF SDRs; changing sovereign credit ratings, and reducing tax avoidance. Use of these options are outside the control of health sector actors; however, health stakeholders must champion their adoption on the global stage to help address urgent HCWF challenges and improve global health security and health system resilience. PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 31 32 Policy brief PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 32 33 What steps can improve and promote investment in the health and care workforce? REFERENCES Abimbola S et al. (2017). Where there is no policy: governing the posting and transfer of primary health care workers in Nigeria. Int J Health Plann Manage.32(4):492–508. doi: 10.1002/hpm.2356. Adovor E et al. (2021). Medical brain drain: how many, where and why? J Health Econ.76:102409. doi: 10.1016/j.jhealeco.2020.102409. AHEAD (2023). EU’s health workforce projects cluster. AHEAD (https://ahead.health/eus-health-workforce- projects-cluster/, accessed 20 February 2023). Aluttis CB (2014). The workforce for health in a globalized context – global shortages and international migration. Glob Health Act.7(1):1–8. Alsan M, Garrick O, Graziani G (2019). Does diversity matter for health? experimental evidence from Oakland. Amer Econ Rev.109(12):4071–11. doi:10.1257/aer.20181446. Andrade MV et al. (2018). Transition to universal primary health care coverage in Brazil: analysis of uptake and expansion patterns of Brazil’s family health strategy (1998–2012). PLoS One.13(8):e0201723. doi: 10.1371/journal.pone.0201723. Asamani JA et al. (2022). Exploring the availability of specialist health workforce education in east and southern Africa: a document analysis. BMJ Glob Health.7(Suppl 1)10.1136/bmjgh-2022-009555. Barroy H, Sparkes S, Dale E (2016). Assessing fiscal space for health in low and middle income countries: a review of the evidence. Geneva: World Health Organization (https://www.who.int/publications/i/item/WHO-HIS-HGF- HFWorkingPaper-16.3, accessed 19 February 2023). Barroy H et al. (2019). Leveraging public financial management for better health in Africa: key bottlenecks and opportunities for reform. Health Financing Working paper No.14. Geneva: World Health Organization (https://www.who.int/publications/i/item/WHO-UHC- HGF-HFWorkingPaper-19.2, accessed 19 February 2023). Barroy H et al. (2020). If you’re not ready, you need to adapt: lessons for managing public finances from the COVID-19 response. Social Health Protection Network, 26 October 2020 (https://p4h.world/en/blog-lessons-for- managing-public-finances-from-COVID-19-response, accessed 20 February 2023). Baxter PE et al. (2015). Leaders’ experiences and perceptions implementing activity-based funding and pay-for- performance hospital funding models: a systematic review. Health Policy.119(8):1096–110. doi: 10.1016/j.healthpol.2015.05.003. Bernal-Delgado E, Al Tayara L (2022). How does Spain’s health sector contribute to the economy? Health and the Economy: A series of country snapshots. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies (https://eurohealthobservatory.who.int/publications/i/ho w-does-spain-s-health-sector-contribute-to-the- economy, accessed 11 December 2022). Boniol M et al. (2022). The global health workforce stock and distribution in 2020 and 2030: a threat to equity and “universal” health coverage? BMJ Glob Health.7(6)10.1136/bmjgh-2022-009316. Borghi J et al. (2015). In Tanzania, the many costs of pay-for- performance leave open to debate whether the strategy is cost-effective. Health Aff (Millwood).34(3):406–14. doi: 10.1377/hlthaff.2014.0608. Buchan J, Catton H, Shaffer F (2022). Sustain and retain in 2022 and beyond: The global nursing workforce and the COVID-19 pandemic. Philidelphia: ICNM - International Centre on Nurse Migration (https://www.icn.ch/node/1463, accessed 20 February 2023). Buchan JA (2020). COVID-19 and the international supply of nurses: report for the International Council of Nurses. Geneva: International Council of Nurses. Buchan JC (2019). Labour market change and the international mobility of health workers. The Health Foundation. Bundred PE, Levitt C (2000). Medical migration: who are the real losers? Lancet.356(9225):245–6. doi: 10.1016/s0140-6736(00)02492-2. Burton MJ et al. (2021). The Lancet Global Health Commission on global eye health: vision beyond 2020. Lancet Glob Health.9(4):e489-e551. doi: 10.1016/s2214-109x(20)30488-5. Bvumbwe T, Mtshali N (2018). Nursing education challenges and solutions in sub Saharan Africa: an integrative review. BMC Nurs.17:3. doi: 10.1186/s12912-018- 0272-4. Carpio CA, Bench N (2015). The health workforce in Latin America and the Caribbean: an analysis of Colombia, Costa Rica, Jamaica, Panama, Peru, and Uruguay. Directions in development. Washington, DC: The World Bank. Chen J et al. (2021). COVID‐19 health system response monitor: Singapore. New Delhi: New Delhi: World Health Organization Regional Office for South‐East Asia (https://apo.who.int/publications/i/item/covid-19-health- system-response-monitor-singapore, accessed 18 February 2023). Clemens M, Dempster H (2021). Ethical recruitment of health workers: using bilateral cooperation to fulfill the World Health Organization’s Global Code of Practice. Washington DC: Center for Global Development. Co M, Chung PH, Chu KM (2021). Online teaching of basic surgical skills to medical students during the COVID-19 pandemic: a case-control study. Surg Today.51(8):1404– 9. doi: 10.1007/s00595-021-02229-1. Cometto G, Campbell J (2016). Investing in human resources for health: beyond health outcomes. Hum Resour Health.14(1):51. PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 33 34 Policy brief Cometto G et al. (2019). Analysing public sector institutional capacity for health workforce governance in the South- East Asia Region of WHO. Hum Resour Health.17(1):43. doi: 10.1186/s12960-019-0385-1. Couper I et al. (2018). Curriculum and training needs of mid-level health workers in Africa: a situational review from Kenya, Nigeria, South Africa and Uganda. BMC Health Serv Res.18(1):553. doi: 10.1186/s12913-018- 3362-9. Crispino KT, Rocha ICN (2021). Enhancing healthcare professional practice in the Philippines toward ASEAN integration through the continuing professional development law. ASEAN J Comm Engag.5(2):376–95. Cylus J, Permanand G, Smith PC (2018). Making the economic case for investing in the health system: What is the evidence that health systems advance economic and fiscal objectives? In: Kluge H, Figueras J (eds). Health Systems for Prosperity and Solidarity Policy brief. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies. Czabanowska K, Kuhlmann E (2021). Public health competences through the lens of the COVID-19 pandemic: what matters for health workforce preparedness for global health emergencies. Int J Health Plann Manage.36(S1):14–9. doi: 10.1002/hpm.3131. Dahn B, Woldermariam A, Perry H, Maeda A, Glahn D, Panjabi R, et al. (2015). Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations. (http://www.healthenvoy.org/wp- content/uploads/2015/07/CHW-Financing-FINAL-July-15 -2015.pdf, accessed 03 March 2023). De Kock JH et al. (2021). A rapid review of the impact of COVID-19 on the mental health of healthcare workers: implications for supporting psychological well-being. BMC Public Health.21(1):104. doi: 10.1186/s12889- 020-10070-3. Department of Health (2018). Reports of the Task Force for the Framework for Safe Nurse Staffing and Skill Mix in General and Specialist Medical and Surgical Care Settings in Ireland 2018. Dublin: Government of Ireland (https://www.gov.ie/en/collection/bebf28-taskforce- publications/#, accessed 20 February 2023). Deussom R et al. (2022). Putting health workers at the centre of health system investments in COVID-19 and beyond. Fam Med Community Health.10(2)10.1136/fmch-2021-001449. Doshmangir L et al. (2022). The future of Iran’s health workforce. Lancet.400(10356):883. doi: 10.1016/s0140- 6736(22)01608-7. Drennan VM, Ross F (2019). Global nurse shortages – the facts, the impact and action for change. Br Med Bull.130(1):25–37. doi: 10.1093/bmb/ldz014. Efendi F et al. (2018). The situational analysis of nursing education and workforce in Indonesia. Malaysian J Nursing.9(4):20–9. European Commission (2021a). Official launch event of the health workforce projects cluster. Brussels: European Commission (https://health.ec.europa.eu/system/files/2021- 09/ev_20210920_ag_en_0.pdf, accessed 20 February 2023). European Commission (2021b). The Recovery and Resilience Facility supports the promotion of digital skills. Brussels: European Commission. European Commission (2023a). Green Transition, Recovery and Resilience Scoreboard. Brussels: European Commission. European Commission (2023b). European Social Fund Plus. Brussels: European Commission (https://ec.europa.eu/european-social-fund- plus/en/what-esf; accessed 20 February 2023). Fagan EB et al. (2015). Family medicine graduate proximity to their site of training: Policy options for improving the distribution of primary care access. Family Med.47(2):124–30. Fahy N, Williams GA, COVID-19 Health System Response Monitor Network (2021). Use of digital health tools in Europe before, during and after COVID-19. Health Systems and Policy Analysis Series. Policy Brief 42. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies. Farrell J et al. (2022). Who enters the health workforce? An examination of racial and ethnic diversity. Washington, DC: Fitzhugh Mullan Institute for Health Workforce Equity, George Washington University (www.gwhwi.org/hweseries.html, accessed 20 February 2023). Feldacker C et al. (2017). Continuing professional development for medical, nursing, and midwifery cadres in Malawi, Tanzania and South Africa: a qualitative evaluation. PLoS One.12(10):e0186074. doi: 10.1371/journal.pone.0186074. Filipe HP, Mack HG, Golnik KC (2017). Continuing professional development: Progress beyond continuing medical education. Annal Eye Sci.2(7):46. Foster K (2017). Government “quietly goes back on promise to fund 10,000 new nursing degree places”, claim universities. The Independent, 28 June 2017. (https://www.independent.co.uk/news/health/nursing- degree-places-10000-promise-nhs-staff-shortages-nurse s-government-tories-conservatives-university-education- funding-a7811671.html accessed 10 February 2023). Frehywot S et al. (2010). Compulsory service programmes for recruiting health workers in remote and rural areas: do they work? Bull World Health Organ.88(5):364–70. doi: 10.2471/blt.09.071605. Frehywot S et al. (2013). E-learning in medical education in resource constrained low- and middle-income countries. Hum Resour Health.11:4. doi: 10.1186/1478-4491-11-4. Frenk J et al. (2010). Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet.376(9756):1923–58. doi: 10.1016/s0140-6736(10)61854-5. PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 34 35 What steps can improve and promote investment in the health and care workforce? Gachanja F, Mwangi N, Gicheru W (2021). E-learning in medical education during COVID-19 pandemic: experiences of a research course at Kenya Medical Training College. BMC Med Educ.21(1):612. doi: 10.1186/s12909-021-03050-7. Gajewski J et al. (2019). The contribution of non-physician clinicians to the provision of surgery in rural Zambia – a randomised controlled trial. Hum Resour Health.17(1):60. doi: 10.1186/s12960-019-0398-9. Goodfellow A et al. (2016). Predictors of primary care physician practice location in underserved urban or rural areas in the United States: a systematic literature review. Acad Med.91(9):1313-21. doi: 10.1097/ACM.0000000000001203. Gordon S (2022). Manitoba government moves to end mandating overtime, adds 2,000 health-care professionals with $200-million investment. News Release. Province of Manitoba website. (https://news.gov.mb.ca/news/print,index.html?item=56 864&posted=2022-11-10, accessed 28 February 2023). Govindaraj R (2018). Strengthening post-Ebola health systems : from response to resilience in Guinea, Liberia, and Sierra Leone. Washington, DC: World Bank. (https://openknowledge.worldbank.org/handle/10986/2 7618, accessed 1 March 2023). Greer SL (2012). Interdepartmental units and committees. In: McQueen DV et al. eds. Intersectoral governance for health in all policies: structures, actions and experiences. London: European Observatory on Health Systems and Policies. Greer SL et al. (2022). Centralizing and decentralizing governance in the COVID-19 pandemic: the politics of credit and blame. Health Policy.126(5):408–17. doi: 10.1016/j.healthpol.2022.03.004. Grobler L et al. (2009). Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database Syst Rev.(1):Cd005314. doi: 10.1002/14651858.CD005314.pub2. Guillén E, Buissonnière M, Lee CT (2021). From lionizing to protecting health care workers during and after COVID- 19-systems solutions for human tragedies. Int J Health Plann Manage.36(S1):20–5. doi: 10.1002/hpm.3138. Haldane V et al. (2021). Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries. Nat Med.27(6):964–80. doi: 10.1038/s41591- 021-01381-y. Healy J, McKee M (2002). Improving performance within the hospital. In M McKee, J Healy (eds.) Hospitals in a Changing Europe. Buckingham, Philadelphia: Open University Press. IADB (2023). Public health. Washington, DC: Inter-American Development Bank (https://www.iadb.org/en/about- us/public-health%2C6222.html, accessed 18 February 2023). IHS Markit (2021). The complexities of physician supply and demand: projections from 2019 to 2034. Washington, DC: Association of American Medical Colleges. ILO (1999). Report of the Director General - decent work. Geneva: International Labour Organization (https://www.ilo.org/public/english/standards/relm/ilc/ilc8 7/rep-i.htm, accessed 1 March 2022). Joarder T et al. (2018). Retaining doctors in rural Bangladesh: a policy analysis. Int J Health Policy Manag.7(9):847–58. Khampang R et al. (2016). Pay-for-performance in resource- constrained settings: lessons learned from Thailand’s quality and outcomes framework. F1000Research.5(2700)10.12688/f1000research.9897.1. Khan MS et al. (2019). What can motivate lady health workers in Pakistan to engage more actively in tuberculosis case-finding? BMC Public Health.19(1):999. doi: 10.1186/s12889-019-7326-8. Khan N et al. (2020). A pay for performance scheme in primary care: meta-synthesis of qualitative studies on the provider experiences of the quality and outcomes framework in the UK. BMC Fam Pract.21(1):142. doi: 10.1186/s12875-020-01208-8. Khanijahani A et al. (2021). A systematic review of racial/ethnic and socioeconomic disparities in COVID-19. Int J Equity Health.20(1):248. doi: 10.1186/s12939-021- 01582-4. Lagarde M, Huicho L, Papanicolas I (2019). Motivating provision of high quality care: it is not all about the money. BMJ.366:l5210. doi: 10.1136/bmj.l5210. Lall D et al. (2020). Team-based primary health care for non- communicable diseases: complexities in South India. Health Policy Plan.35(Supplement_2):ii22-ii34. doi: 10.1093/heapol/czaa121. Lassi ZS et al. (2013). Quality of care provided by mid-level health workers: systematic review and meta-analysis. Bull World Health Organ.91(11):824-33i. doi: 10.2471/blt.13.118786. Lauer JA et al. (2017). Pathways: the health system, health employment, and economic growth. In: WHO. Health employment and economic growth: an evidence base. Geneva: World Health Organization (https://apps.who.int/iris/handle/10665/326411, accessed 20 February 2023). Liu JX et al. (2017). Global health workforce labor market projections for 2030. Hum Resour Health.15(1):11. doi: 10.1186/s12960-017-0187-2. LLF (nd). A guide to the Lives and Livelihoods Fund: a unique global partnership for financing projects towards a better future in Islamic Development Bank member countries. Jeddah: Lives and Livelihoods Fund (https://www.isdb.org/sites/default/files/media/document s/2020-04/LLF%20-%20Guide%20-%20En%20- %20Updated.pdf, accessed 20 February 2023). Maier CB (2022). Skill-mix innovation, effectiveness and implementation: improving primary and chronic care. Cambridge: Cambridge University Press. Marini G, Yang L (2021). Globally bred Chinese talents returning home: an analysis of a reverse brain-drain flagship policy. Science and Public Policy.48(4):541–52. doi: 10.1093/scipol/scab021. PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 35 36 Policy brief Martinez J, Martineau T (2001). Introducing performance management in national health systems: issues on policy and implementation. An IHSD Issues Note, Barcelona. McCauley LP (2021). Committee on implementing high- quality primary care. Washington, DC: National Academies of Sciences, Engineering, Medicine. McKee M editor (2021). Drawing light from the pandemic: a new strategy for health and sustainable development. A review of the evidence for the Pan-European Commission on Health and Sustainable Development. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies (https://eurohealthobservatory.who.int/publications/m/dr awing-light-from-the-pandemic-a-new-strategy-for- health-and-sustainable-development, accessed 19 February 2023). McPake B et al. (2013). Why do health labour market forces matter? Bull World Health Organ.91(11):841– 6. doi: 10.2471/blt.13.118794. McPake B et al. (2016). Implications of dual practice for universal health coverage. Bull World Health Organ.94(2):142–6. doi: 10.2471/blt.14.151894. Micah AE et al. (2022). Development assistance for human resources for health, 1990–2020. Hum Resour Health.20:51. Mills EJ et al. (2011). The financial cost of doctors emigrating from sub-Saharan Africa: human capital analysis. BMJ.343:d7031. doi: 10.1136/bmj.d7031. Ministry of Health (2011). Ghana human resources for health country profile. Greater Accra: Ministry of Health Republic of Ghana. Mullan F et al. (2011). Medical schools in sub-Saharan Africa. Lancet.377(9771):1113–21. doi: 10.1016/s0140- 6736(10)61961-7. Mullan F, Frehywot S (2007). Non-physician clinicians in 47 sub-Saharan African countries. Lancet.370(9605):2158– 63. doi: 10.1016/s0140-6736(07)60785-5. Munday D et al. (2018). Palliative care in Nepal: current steps to achieving universal health coverage. Eur J Palliat Care.25(1):40–6. Nimavat N et al. (2021). Online medical education in India – different challenges and probable solutions in the age of COVID-19. Adv Med Educ Pract.12:237–43. doi: 10.2147/amep.S295728. O’Reilly P et al. (2017). Assessing the facilitators and barriers of interdisciplinary team working in primary care using normalisation process theory: an integrative review. PLoS One.12(5):e0177026. doi: 10.1371/journal.pone.0177026. OECD (2020). Contribution of migrant doctors and nurses to tackling COVID-19 crisis in OECD countries. OECD Policy Responses to Coronavirus (COVID-19). Paris: Organisation for Economic Co-operation and Development (https://www.oecd.org/coronavirus/policy- responses/contribution-of-migrant-doctors-and-nurses-t o-tackling-covid-19-crisis-in-oecd-countries-2f7bace2/, accessed 19 February 2023). Okoroafor SC et al. (2022). An overview of health workforce education and accreditation in Africa: implications for scaling-up capacity and quality. Hum Resour Health.20(1):37. doi: 10.1186/s12960-022-00735-y. Olsen J (2017). Chapter 14. Primary care: paying general practitioners. In: Olsen J. Principles in health economics and policy. Oxford: Oxford University Press, pp. 169–84. Okonjo-Iweala N, Shanmugaratnam T, Summers LH (2021). Rethinking multilateralism for a pandemic era. Incremental changes to existing mechanisms have failed; a fundamental reset is needed. Financ Dev.58:4. Or Z, Al Tayara L (2022). How does France’s health sector contribute to the economy? Health and the Economy: A series of country snapshots. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies (https://eurohealthobservatory.who.int/publications/i/ho w-does-france-s-health-sector-contribute-to-the- economy, accessed 11 December 2022). Ozawa S, Clark S, Portnoy A, Grewal S, Brenzel L, Walker DG. (2016). Return On Investment From Childhood Immunization In Low- And Middle-Income Countries, 2011-20. Health Aff (Millwood).35(2):199-207 PAHO (2020). Fiscal space for health in Latin America and the Caribbean. Washington, DC: Pan American Health Organization (https://iris.paho.org/handle/10665.2/52410, accessed 19 February 2023). Phelan SM et al. (2017). Medical school factors associated with changes in implicit and explicit bias against gay and lesbian people among 3492 graduating medical students. J Gen Intern Med.32:1193–201. doi: 10.1007/s11606-017-4127-6. Phillips RL, Petterson S, Bazemore A (2013). Do residents who train in safety net settings return for practice? Acad Med.88(12):1934–40. doi: 10.1097/ACM.0000000000000025. Pu X, Gu Y, Wang X (2018). Provider payment to primary care physicians in China: background, challenges, and a reform framework. Prim Health Care Res Dev.20:e34. doi: 10.1017/s146342361800021x. Pu X et al. (2020). Realigning the provider payment system for primary health care: a pilot study in a rural County of Zhejiang Province, China. Primary Health Care Res Dev.21:e43. Pudpong N et al. (2017). A final-year nursing student survey: rural attitudes, perceived competencies and intention to work across five Asian countries. BMC Nurs.16:13. doi: 10.1186/s12912-017-0208-4. Purohit B, Martineau T, Sheikh K (2016). Opening the black box of transfer systems in public sector health services in a Western state in India. BMC Health Serv Res.16:419. Rawal LB et al. (2015). Developing effective policy strategies to retain health workers in rural Bangladesh: a policy analysis. Hum Resour Health.13:36. Rowe AK et al. (2018). Effectiveness of strategies to improve health-care provider practices in low-income and middle-income countries: a systematic review. Lancet Glob Health.6(11):e1163-e75. doi: 10.1016/s2214- 109x(18)30398-x. PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 36 37 What steps can improve and promote investment in the health and care workforce? SBS News (2021). There are few Indigenous doctors in Australia. This course hopes to change that. SBS News, 7 January (https://www.sbs.com.au/news/article/there- are-few-indigenous-doctors-in-australia-this-course-hop es-to-change-that/icbv5pak6, accessed 20 February 2023). Scheil-Adlung X (2015). Global evidence on inequities in rural health protection: new data on rural deficits in health coverage for 174 countries. Geneva: International Labour Organization. Shah SM et al. (2016). Motivation and retention of physicians in primary healthcare facilities: a qualitative study from Abbottabad, Pakistan. Int J Health Policy Manag.5(8):467–75. doi: 10.15171/ijhpm.2016.38. Shaw C (2006). Managing the performance of health professionals. In: Dubois CA, McKee M, Nolte E (eds.). Human Resources for Health in Europe. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies. Shen MJ et al. (2018). The effects of race and racial concordance on patient-physician communication: a systematic review of the literature. J Racial Ethn Health Disparities.5(1):117–140. doi:10.1007/s40615-017- 0350-4. Srinivasan V, Chandwani R (2014). HRM innovations in rapid growth contexts: the healthcare sector in India. Int J Human Resource Manag.25(10):1505–25. Stenberg K et al. (2017). Financing transformative health systems towards achievement of the health sustainable development goals: a model for projected resource needs in 67 low-income and middle-income countries. Lancet Glob Health.5(9):e875-e87. doi: 10.1016/s2214- 109x(17)30263-2. Tandon A, Cashin C (2010). Assessing public expenditure on health from a fiscal space perspective. Health, Nutrition and Population (HNP) discussion paper. Washington, DC: World Bank (https://openknowledge.worldbank.org/handle/10986/1 3613, accessed 19 February 2023). Tangcharoensathien V et al. (2018a). Health systems development in Thailand: a solid platform for successful implementation of universal health coverage. Lancet.391(10126):1205–23. doi: 10.1016/s0140- 6736(18)30198-3. Tangcharoensathien V et al. (2018b). Managing in- and out- migration of health workforce in selected countries in South East Asia region. Int J Health Policy Manag.7(2):137–43. doi: 10.15171/ijhpm.2017.49. Thompson M, Walton-Roberts M (2019). International nurse migration from India and the Philippines: the challenge of meeting the sustainable development goals in training, orderly migration and healthcare worker retention. J Ethnic Migration Stud.45(14):2583–99. doi: 10.1080/1369183X.2018.1456748. UHC2030 (2020). Public financial management for universal health coverage: why and how it matters. (https://www.uhc2030.org/fileadmin/uploads/uhc2030/ Documents/About_UHC2030/UHC2030_Working_Grou ps/2017_Financial_Management_Working_Group/UHC_ PFM_policy_note_02XII20_online.pdf, accessed 19 February 2023). van Ryn M et al. (2015). Medical school experiences associated with change in implicit racial bias among 3547 students: a medical student CHANGES study report. J Gen Intern Med.30:1748–56. doi: 10.1007/s11606-015-3447-7. van Stralen AC, Carvallo C, Girardi SN (2022). International strategies for flexibilization of the regulation of health workforce practices in response to the COVID-19 pandemic: a scoping review. Cad Saúde Pública.38: e00116321. doi: 10.1590/0102-311x00116321. WHO (2010). Global policy recommendations: increasing access to health workers in remote and rural areas through improved retention. Geneva: World Health Organization (https://apps.who.int/iris/bitstream/handle/10665/44369/ 9789241564014_eng.pdf?sequence, accessed 19 February 2023). WHO (2016a). Global strategy on human resources for health: workforce 2030. Geneva: World Health Organization (https://www.who.int/publications/i/item/978924151113 1, accessed 19 February 2023). WHO (2016b). Working for health and growth: investing in the health workforce. Report of the High-Level Commission on Health Employment and Economic Growth. Geneva: World Health Organization (https://www.who.int/publications/i/item/978924151130 8, accessed 19 February 2023). WHO (2017). Health employment and economic growth an evidence base. Geneva: World Health Organization(https://apps.who.int/iris/handle/10665/326 411, accessed 12 October 2022). WHO (2018). Imbalances in rural primary care: a scoping literature review with emphasis on the WHO European Region. Geneva: World Health Organization (https://apps.who.int/iris/handle/10665/346351, accessed 19 February 2023). WHO (2021a). Impact of COVID-19 on human resources for health and policy response: the case of Plurinational State of Bolivia, Chile, Colombia, Ecuador and Peru. Overview of findings from five Latin American countries. Geneva: World Health Organization (https://apps.who.int/iris/handle/10665/350640, accessed 19 February 2023). WHO (�2021b)�. The impact of COVID-19 on health and care workers: a closer look at deaths. Geneva: World Health Organization (https://apps.who.int/iris/handle/10665/345300, accessed 19 February 2023). WHO (2021c). WHO guideline on health workforce development, attraction, recruitment and retention in rural and remote areas. Geneva: World Health Organization (https://www.who.int/publications/i/item/978924002422 9, accessed 1 March 2023). PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 37 38 Policy brief WHO (2023). National Health Workforce Accounts Data Portal. Geneva: World Health Organization (https://apps.who.int/nhwaportal/Home/Index, 1 March 2023). WHO Council on the Economics of Health for All (2021). Financing health for all: increase, transform and redirect. Geneva: World Health Organization (https://www.who.int/publications/m/item/council-brief- no-2, accessed 20 February 2023). WHO Global Health Observatory (2022). Domestic general government health expenditure (GGHE-D) as percentage of general government expenditure (GGE) (%). Geneva: World Health Organization (https://www.who.int/data/gho/data/indicators/indicator- details/GHO/domestic-general-government-health-expen diture-(gghe-d)-as-percentage-of-general-government- expenditure-(gge), accessed 2 December 2022). WHO, ILO (2022). The gender pay gap in the health and care sector. A global analysis in the time of COVID-19. Geneva: World Health Organization and the International Labour Organization (https://www.ilo.org/wcmsp5/groups/public/—- dgreports/—-dcomm/—-publ/documents/publication/wc ms_850909.pdf, accessed 19 February 2023). WHO Regional Office for Africa (2021). The state of the health workforce in the WHO African Region—2021. Brazzaville: WHO Regional Office for Africa (https://www.afro.who.int/publications/state-health- workforce-who-african-region-2021, accessed 20 February 2023). WHO Regional Office for Europe (2022). Health and care workforce in Europe: time to act. Copenhagen: WHO Regional Office for Europe. WHO Regional Office for South-East Asia (2018a). Decade for health workforce strengthening in the South-East Asia Region 2015–2024, Second review of progress. New Delhi: WHO Office for South-East Asia (https://apps.who.int/iris/handle/10665/274310, accessed 19 February 2023). WHO Regional Office for South-East Asia (2018b). Mid-level health workers: a review of the evidence. New Delhi: WHO Office for South-East Asia (https://apps.who.int/iris/handle/10665/259878, accessed 19 February 2023). Wibulpolprasert S, Pengpaibon P (2003). Integrated strategies to tackle the inequitable distribution of doctors in Thailand: four decades of experience. Hum Resour Health.1(1):12. doi: 10.1186/1478-4491-1-12. Williams D, Thomas S (2017). The impact of austerity on the health workforce and the achievement of human resources for health policies in Ireland (2008–2014). Hum Resour Health.15(1):1–8. Willis DE et al. (2021). COVID-19 vaccine hesitancy: race/ethnicity, trust, and fear. Clin Trans Sci.14(6):2200– 07. doi: 10.1111/cts.13077. Winkelmann J et al. (2022). European countries’ responses in ensuring sufficient physical infrastructure and workforce capacity during the first COVID-19 wave. Health Policy.126(5):362–72. doi: 10.1016/j.healthpol.2021.06.015. World Bank (2022a). Personal remittances, received (% of GDP) – Philippines. Washington, DC: World Bank (https://data.worldbank.org/indicator/BX.TRF.PWKR.DT.G D.ZS?locations=PH, accessed 20 February 2023). World Bank (2022b). Poverty and Shared Prosperity 2022: Correcting Course. Washington, DC: World Bank. (https://openknowledge.worldbank.org/bitstream/handle /10986/37739/9781464818936.pdf, accessed 9 December 2012). Zapata T, Buchan J, Azzopardi-Muscat N (2021). The health workforce: central to an effective response to the COVID-19 pandemic in the European region. Int J Health Plann Manage.36(S1):9–13. doi: 10.1002/hpm.3150. Ziemann M et al. (2022). How is the health workforce educated and trained? An examination of social mission in health professions education. Washington, DC: Fitzhugh Mullan Institute for Health Workforce Equity, George Washington University. PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 38 39 What steps can improve and promote investment in the health and care workforce? PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 39 40 Policy brief PolicyBrief_PB_54_PRINT.qxp_Policy_brief_A4 21/03/2023 10:33 Page 40 Keywords: HEALTH MANAGEMENT AND PLANNING PERSONNEL STAFFING AND SCHEDULING - organization and administration HEALTH POLICY HEALTH SYSTEMS PLANS – organization and administration INTERSECTORAL COOPERATION This policy brief is one of a new series to meet the needs of policy-makers and health system managers. The aim is to develop key messages to support evidence-informed policy-making and the editors will continue to strengthen the series by working with authors to improve the consideration given to policy options and implementation. What is a Policy Brief? A policy brief is a short publication specifically designed to provide policy makers with evidence on a policy question or priority. Policy briefs • Bring together existing evidence and present it in an accessible format • Use systematic methods and make these transparent so that users can have confidence in the material • Tailor the way evidence is identified and synthesised to reflect the nature of the policy question and the evidence available • Are underpinned by a formal and rigorous open peer review process to ensure the independence of the evidence presented. Each brief has a one page key messages section; a two page executive summary giving a succinct overview of the findings; and a 20 page review setting out the evidence. The idea is to provide instant access to key information and additional detail for those involved in drafting, informing or advising on the policy issue. Policy briefs provide evidence for policy-makers not policy advice. They do not seek to explain or advocate a policy position but to set out clearly what is known about it. They may outline the evidence on different prospective policy options and on implementation issues, but they do not promote a particular option or act as a manual for implementation. © World Health Organization 2023 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies) Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site (http://www.euro.who.int/pubrequest). All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full. Please address requests about the publication to: contact@obs.who.int. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies or any of its part- ners concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the European Observa- tory on Health Systems and Policies in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the European Observatory on Health Systems and Policies to verify the information contained in this publica- tion. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the European Observatory on Health Systems and Policies or any of its partners be liable for damages arising from its use. The views expressed by authors or editors do not necessarily represent the decisions or the stated policies of the European Observatory on Health Systems and Policies or any of its partners. The Policy Brief Series 1. How can European health systems support investment in and the implementation of population health strategies? David McDaid, Michael Drummond, Marc Suhrcke 2. How can the impact of health technology assessments be enhanced? Corinna Sorenson, Michael Drummond, Finn Børlum Kristensen, Reinhard Busse 3. Where are the patients in decision-making about their own care? Angela Coulter, Suzanne Parsons, Janet Askham 4. How can the settings used to provide care to older people be balanced? Peter C. Coyte, Nick Goodwin, Audrey Laporte 5. When do vertical (stand-alone) programmes have a place in health systems? Rifat A. Atun, Sara Bennett, Antonio Duran 6. How can chronic disease management programmes operate across care settings and providers? Debbie Singh 7. How can the migration of health service professionals be managed so as to reduce any negative effects on supply? James Buchan 8. How can optimal skill mix be effectively implemented and why? Ivy Lynn Bourgeault, Ellen Kuhlmann, Elena Neiterman, Sirpa Wrede 9. Do lifelong learning and revalidation ensure that physicians are fit to practise? Sherry Merkur, Philipa Mladovsky, Elias Mossialos, Martin McKee 10. How can health systems respond to population ageing? Bernd Rechel, Yvonne Doyle, Emily Grundy, Martin McKee 11. How can European states design efficient, equitable and sustainable funding systems for long-term care for older people? José-Luis Fernández, Julien Forder, Birgit Trukeschitz, Martina Rokosová, David McDaid 12. How can gender equity be addressed through health systems? Sarah Payne 13. How can telehealth help in the provision of integrated care? Karl A. Stroetmann, Lutz Kubitschke, Simon Robinson, Veli Stroetmann, Kevin Cullen, David McDaid 14. How to create conditions for adapting physicians’ skills to new needs and lifelong learning Tanya Horsley, Jeremy Grimshaw, Craig Campbell 15. How to create an attractive and supportive working environment for health professionals Christiane Wiskow, Tit Albreht, Carlo de Pietro 16. How can knowledge brokering be better supported across European health systems? John N. Lavis, Govin Permanand, Cristina Catallo, BRIDGE Study Team 17. How can knowledge brokering be advanced in a country’s health system? John. N Lavis, Govin Permanand, Cristina Catallo, BRIDGE Study Team 18. How can countries address the efficiency and equity implications of health professional mobility in Europe? Adapting policies in the context of the WHO Code and EU freedom of movement Irene A. Glinos, Matthias Wismar, James Buchan,Ivo Rakovac 19. Investing in health literacy: What do we know about the co-benefits to the education sector of actions targeted at children and young people? David McDaid 20. How can structured cooperation between countries address health workforce challenges related to highly specialized health care? Improving access to services through voluntary cooperation in the EU Marieke Kroezen, James Buchan, Gilles Dussault, Irene Glinos, Matthias Wismar 21. How can voluntary cross-border collaboration in public procurement improve access to health technologies in Europe? Jaime Espín, Joan Rovira, Antoinette Calleja, Natasha Azzopardi-Muscat, Erica Richardson,Willy Palm, Dimitra Panteli 22. How to strengthen patient-centredness in caring for people with multimorbidity in Europe? Iris van der Heide, Sanne P Snoeijs, Wienke GW Boerma, François GW Schellevis, Mieke P Rijken. On behalf of the ICARE4EU consortium 23. How to improve care for people with multimorbidity in Europe? Mieke Rijken, Verena Struckmann, Iris van der Heide, Anneli Hujala, Francesco Barbabella, Ewout van Ginneken, François Schellevis. On behalf of the ICARE4EU consortium 24. How to strengthen financing mechanisms to promote care for people with multimorbidity in Europe? Verena Struckmann, Wilm Quentin, Reinhard Busse, Ewout van Ginneken. On behalf of the ICARE4EU consortium 25. How can eHealth improve care for people with multimorbidity in Europe? Francesco Barbabella, Maria Gabriella Melchiorre, Sabrina Quattrini, Roberta Papa, Giovanni Lamura. On behalf of the ICARE4EU consortium 26. How to support integration to promote care for people with multimorbidity in Europe? Anneli Hujala, Helena Taskinen, Sari Rissanen. On behalf of the ICARE4EU consortium 27. How to make sense of health system efficiency comparisons? Jonathan Cylus, Irene Papanicolas, Peter C Smith 28. What is the experience of decentralized hospital governance in Europe? Bernd Rechel, Antonio Duran, Richard Saltman 29. Ensuring access to medicines: How to stimulate innovation to meet patients’ needs? Dimitra Panteli, Suzanne Edwards 30. Ensuring access to medicines: How to redesign pricing, reimbursement and procurement? Sabine Vogler, Valérie Paris, Dimitra Panteli 31. Connecting food systems for co-benefits: How can food systems combine diet-related health with environmental and economic policy goals? Kelly Parsons, Corinna Hawkes 32. Averting the AMR crisis: What are the avenues for policy action for countries in Europe? Michael Anderson, Charles Clift, Kai Schulze, Anna Sagan, Saskia Nahrgang, Driss Ait Ouakrim, Elias Mossialos 33. It’s the governance, stupid! TAPIC: a governance framework to strengthen decision making and implementation Scott L. Greer, Nikolai Vasev, Holly Jarman, Matthias Wismar, Josep Figueras 34. How to enhance the integration of primary care and public health? Approaches, facilitating factors and policy options Bernd Rechel 35. Screening. When is it appropriate and how can we get it right? Anna Sagan, David McDaid, Selina Rajan, Jill Farrington, Martin McKee 36. Strengthening health systems resilience: key concepts and strategies Steve Thomas, Anna Sagan, James Larkin, Jonathan Cylus, Josep Figueras, Marina Karanikolos 37. Building on value-based health care Peter C Smith, Anna Sagan, Luigi Siciliani, Dimitra Panteli, Martin McKee, Agnès Soucat, Josep Figueras 38. Regulating the unknown: A guide to regulating genomics for health policy-makers Gemma A Williams, Sandra Liede, Nick Fahy, Kristiina Aittomaki, Markus Perola, Tuula Helander, Martin McKee, Anna Sagan 39. In the wake of the pandemic: Preparing for Long COVID Selina Rajan, Kamlesh Khunti, Nisreen Alwan, Claire Steves, Trish Greenhalgh, Nathalie MacDermott, Anna Sagan, Martin McKee 40. How can we transfer service and policy innovations between health systems? Ellen Nolte, Peter Groenewegen 41. What are the key priority areas where European health systems can learn from each other? Johan Hansen, Alexander Haarmann, Peter Groenewegen, Natasha Azzopardi Muscat, Gianpaolo Tomaselli, Mircha Poldrugovac 42. Use of digital health tools in Europe: Before, during and after COVID-19 Nick Fahy, Gemma A Williams, COVID-19 Health System Response Monitor Network 43. European support for improving health and care systems Nick Fahy, Nicole Mauer, Dimitra Panteli 44. What are patient navigators and how can they improve integration of care? Hannah Budde, Gemma A Williams, Giada Scarpetti, Marieke Kroezen, Claudia B Maier 45. What are the implications of policies increasing transparency of prices paid for pharmaceuticals? Erin Webb, Erica Richardson, Sabine Vogler, Dimitra Panteli 46. How can skill-mix innovations support the implementation of integrated care for people with chronic conditions and multimorbidity? Juliane Winkelmann, Giada Scarpetti, Gemma A Williams, Claudia B Maier 47. Addressing backlogs and managing waiting lists during and beyond the COVID-19 pandemic Ewout van Ginneken, Sarah Reed, Luigi Siciliani, Astrid Eriksen, Laura Schlepper, Florian Tille, Tomas Zapata 48. Does provider competition improve health care quality and efficiency? Luigi Siciliani, Martin Chalkley, Hugh Gravelle 49. Health system performance assessment: A primer for policy-makers Dheepa Rajan, Irene Papanicolas, Marina Karanikolos, Kira Koch, Katja Rohrer-Herold, Josep Figueras 50. Making Health for All Policies: Harnessing the co-benefits of health Scott L. Greer, Michelle Falkenbach, Luigi Siciliani, Martin McKee, Matthias Wismar, Praneetha Vissapragada, Marie C. Montás, Janamarie Perroud, Olivia Rockwell, Josep Figueras 51. How can the EU support sustainable innovation and access to effective antibiotics? Michael Anderson, Dimitra Panteli, Elias Mossialos 52. Global Health Workforce responses to address the COVID-19 pandemic Margaret Ziemann, Candice Chen, Rebecca Forman, Anna Sagan, Patricia Pittman 53. What can intersectoral governance do to strengthen the health and care workforce? Margaret Caffrey, Tara Tancred, Joanna Raven The European Observatory has an independent programme of policy briefs and summaries which are available here: https://eurohealthobservatory.who.int/publications/policy-briefs PolicyBrief_PB_54_COVER_PRINT.qxp_Cover_policy_brief 21/03/2023 10:54 Page 2 The European Observatory on Health Systems and Policies is a partnership that supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of health systems in the European Region. It brings together a wide range of policy-makers, academics and practitioners to analyse trends in health reform, drawing on experience from across Europe to illuminate policy issues. The Observatory’s products are available on its website (www.healthobservatory.eu). What steps can improve and promote investment in the health and care workforce? Enhancing efficiency of spending and rethinking domestic and international financing POLICY BRIEF 54 Barbara McPake Prarthna Dayal Julia Zimmermann Gemma A Williams World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 E-mail: eurocontact@who.int Website: www.euro.who.int HEALTH SYSTEMS AND POLICY ANALYSIS Print ISSN 1997-8065 Web ISSN 1997-8073 PolicyBrief_PB_54_COVER_PRINT.qxp_Cover_policy_brief 21/03/2023 11:55 Page 1