Health workforce: working for health: five-year action plan for health employment and inclusive economic growth (2017–2021): report by the Director-General

E SEVENTY-FOURTH WORLD HEALTH ASSEMBLY A74/12 Provisional agenda item 15 15 April 2021 Health workforce Working for health: five-year action plan for health employment and inclusive economic growth (2017–2021) Report by the Director-General 1. In May 2017, the Seventieth World Health Assembly, through resolution WHA70.6, adopted “Working for Health”: the ILO, OECD and WHO five-year action plan for health employment and inclusive economic growth (2017–2021)1 as a mechanism for coordinating the intersectoral implementation of the recommendations of the United Nations High-Level Commission on Health Employment and Economic Growth, supporting WHO’s Global Strategy on Human Resources for Health: Workforce 2030 and advancing universal health coverage. 2. This report responds to decision WHA73(15) (2020) requesting that the Director-General systematically include as substantive items on the agenda of meetings of the WHO governing bodies, any global strategies or action plans that are scheduled to expire within one year, in order to allow Member States to consider whether these have fulfilled their mandates, and take further action as determined. 3. The Director-General submits this report in the International Year of Health and Care Workers, with its theme #Protect, #Invest, #Together. 4. Delivering primary health care and universal health coverage against the impact of the coronavirus disease (COVID-19) pandemic highlights the need for sustained protection and investment in the workforce for health systems resilience and preparedness. During the pandemic, health and care workers have faced multiple risks related to safety and quality of care, including stress, overburdening, a lack of personal protective equipment, risk of infection and death, quarantine, mental health, social discrimination and attacks, and responsibility to care for friends and family – many of these resulting from decades of underinvestment. 5. This report summarizes progress achieved through the five-year action plan during the period from its adoption in May 2017 to December 2020, and presents a pathway for the continuation of its agenda. The report is informed by an external, independent review of the action plan by the Antwerp 1 International Labour Organization, Organisation for Economic Co-operation and Development, World Health Organization. Five-year action plan for health employment and inclusive economic growth (2017–2021). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/272941/9789241514149-eng.pdf?ua=1, accessed 10 March 2021). A74/12 2 Institute of Tropical Medicine, commissioned by WHO in November 2020 (available on the WHO website).1 Implementation 6. Country impact: The action plan, through its Multi-Partner Trust Fund, has facilitated multisectoral policy engagement, evidence-based planning and decision-making that are guiding investment in expanding education, skills and jobs, and building core capabilities for robust health system strengthening in an initial 16 supported countries and territories,2 while tackling prolonged workforce underinvestment. Dialogue and decisions are informed by health labour market analyses and comprehensive data. In 2020, the programme mobilized actions to support COVID-19 response plans. 7. Recurrent expenditure for health workforce education and employment is the largest component of investments required for universal health coverage.3 Addressing the 6.1 million workforce gap in the African Region alone by 2030 could significantly boost regional rates of job creation.4 For example, in Niger, the “Rural Pipeline Programme”, which the joint programme supports, led to the creation of an estimated 2500 community-based health worker jobs,5 and a similar initiative in Guinea will create 16 000 such community-based jobs by 2025.6 These processes have influenced a strategic shift in mindset, demonstrated through increased multisectoral commitment and engagement in new national workforce policies and investment plans. 8. Regional integration: Enabling the development of harmonized workforce strategies and investment plans in two regional socioeconomic cooperation and integration organizations, the West African Economic and Monetary Union (UEMOA) and Southern Africa Development Community (SADC), which are bolstering investments in education, skills and jobs. Member countries of UEMOA have committed to creating 40 000 new jobs by 2022, while in SADC a new regional strategy and investment plan calls for a 40% increase in workforce investments over the next 10 years.7 These will tackle youth unemployment, gender inequality, decent work and rights, women’s economic participation and social cohesion. 9. Global public health goods: The ILO-OECD-WHO International Platform on Health Worker Mobility was launched to advance knowledge and cooperation on health worker mobility. The platform has supported the WHO Global Code of Practice on the International Recruitment of Health Personnel by convening Member States, national regulatory bodies, employers’ associations, trade unions, 1 Available at https://www.who.int/publications/i/item/9789240023703, accessed 12 April 2021. 2 Benin, Cambodia, Chad, Guinea, Kyrgyzstan, Mali, Mauritania, Nepal, Niger, Pakistan, Rwanda, Somalia, South Africa, Sri Lanka, Sudan and the occupied Palestinian territory, including east Jerusalem. 3 Stenberg K, Hanssen O, Edejer TT, Bertram M, Brindley C, Meshreky A, et al. 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. 2017;5:E875–87. doi:10.1016/S2214-109X(17)30263-2. 4 The African Regional Framework for the implementation of the global strategy on human resources for health: Workforce 2030: report of the Secretariat. Document AFR/RC67/11 (2017) (https://apps.who.int/iris/handle/10665/260238, accessed 21 March 2021). 5 See document A73/24 Rev.1. 6 Working for Health MPTF Annual Report 2019 (http://mptf.undp.org/document/download/24134, accessed 24 March 2021). 7 SADC Health Workforce Strategic Plan: 2020–2030 – investing in the health workforce and decent work as a catalyst for universal health coverage (publication pending). A74/12 3 certification agencies and relevant international organizations (ILO, IOM, OECD, World Bank and WTO). Activities have captured mobility trends and contributed to migration-related policies at the global and national levels. Notably, the Platform informed the 10-year review of the WHO Global Code’s relevance and effectiveness, the incorporation of Code principles in the World Trade Report 2019, and the reflection of Code principles in recruitment policies, including those of Germany and the United Kingdom of Great Britain and Northern Ireland, and the Alliance for Ethical International Recruitment Practices in the United States of America. 10. An Inter-agency Data Exchange between WHO, ILO and OECD was created that consolidates workforce data and information. The exchange is helping to analyse broad workforce, economic and labour market data for evidence-based policy- and decision-making and investment choices, and is being expanded to include UNESCO, World Bank and others. It has made information more widely accessible, ensured integration of data sets, reduced reporting burden and enabled a better understanding of health labour market dynamics. The data exchange has supported decision-making in more than 65 countries and contributed to national health workforce accounts in 193 countries. Additionally, it has informed gender analysis and commitments to address inequity in the global health workforce, which is almost 70% female.1 11. Gender workforce issues have been highlighted in high-level events such as the G20 and G7 discussions, and universal health coverage, job creation and women’s empowerment have been promoted through the implementation of the Third United Nations Decade for the Eradication of Poverty (2018–2027).2 12. Multisectoral policy dialogue, analysis and investment approaches on job creation, skills and education were applied towards the development of draft strategic directions on nursing and midwifery 2021–2025, aimed at informing investments to close the global gap of 6 million nurses.3 Relevance and effectiveness 13. An independent review of the “relevance” and “effectiveness” of the action plan was undertaken, applying the approach used for the review of the WHO Global Code of Practice on the International Recruitment of Health Personnel.4,5 14. The review found that the action plan remains highly relevant, as a strategic mechanism to address the impact of COVID-19, and the persistent workforce challenges, including the mismatch in supply 1 Delivered by women, led by men: a gender and equity analysis of the global health and social workforce. Human Resources for Health Observer, 24 May 2019 https://www.who.int/hrh/resources/health-observer24/en/, accessed 24 March 2021. 2 https://www.un.org/development/desa/socialperspectiveondevelopment/united-nations-decade-for-the-eradication- of-poverty/third.html, accessed 25 March 2021. 3 Available at https://www.who.int/publications/m/item/global-strategic-directions-for-nursing-and-midwifery-2021- 2025, accessed 12 April 2021. 4 See document A73/9. 5 Relevance: the extent – noting the context of the COVID-19 pandemic - to which the Working for Health Programme and its five-year action plan continue to be pertinent and can contribute to countries’ efforts to address challenges in relation to the health and social care workforce and health systems strengthening. Effectiveness: the extent to which the implementation of the five-year action plan deliverables and immediate actions, via the Working for Health Programme, have resulted in evidence-informed changes concerning health workforce policy and strengthening at country, regional and global levels. A74/12 4 and demand with needs, maldistribution, misalignment between education and health, inadequate working conditions and the increased complexity of international mobility. 15. Commitments for universal health coverage require robust health systems and people-centred service delivery models, for which a sustainable and funded health workforce is key. This is expressed in the political declaration of the high-level meeting on universal health coverage1 and the Astana Declaration on Primary Health Care and reflected in WHO’s Thirteenth General Programme of Work 2019–2023. 16. The COVID-19 pandemic highlights gaps in the availability, preparedness and protection of health workers, for delivering essential services. WHO also recommends adequate staffing levels for facilities to mitigate risk burden of outbreaks.2 A skilled, prepared, protected and motivated health workforce is a fundamental pillar of primary health care, including making essential public health functions a reality. 17. The review’s findings on effectiveness indicated challenges in both the period of implementation, which overlapped with the COVID-19 pandemic, and the limited resources from donor agencies, amounting to US$ 7 million in Multi-Partner Trust Fund contributions out of a proposed US$ 70 million budget for the action plan as submitted to the Seventieth World Health Assembly. Emerging results show progress, and the fund established for the action plan is a functioning instrument that should be continued, along with greater engagement and leadership domestically and globally, to maximize its visibility and uptake. Lessons and challenges 18. Sustainable long-term funding for the workforce is more urgent than ever given the economic and health impact of the pandemic. As governments and economies consider their recovery plans, investments are needed to build a sustainable health and care workforce responsive to population needs, universal health coverage and health security. The pandemic presents a transformational moment for investments in health systems and future workforce capabilities. 19. Capacity, visibility and advocacy to integrate sustainable workforce investments within global health policy and investment platforms remains a challenge. Stronger collaboration is required at regional and country level to capacitate key decision makers and stakeholders to successfully carry forward this “complex” multisectoral agenda and mobilize the sustained levels of domestic and donor funding required for integrated people-centred service delivery. 20. Despite the evidence from the High-Level Commission on Health Employment and Economic Growth, decisions of the United Nations General Assembly and World Health Assembly, and by WHO, ILO and OECD, and the statements and commitments in the G7 and G20, many global and national actors continue to perceive workforce investment as a recurrent cost, constrained by macroeconomic fiscal policy. Sustained investment over several domestic political cycles remains complex and requires long-term commitment and solid institutions. However, the action plan has demonstrated that political commitments can drive multisectoral investment choices; for example, through the results of tackling 1 Political declaration of the high-level meeting on universal health coverage. https://undocs.org/en/A/RES/74/2, accessed 14 March 2021. 2 Minimum requirements for infection prevention and control programmes. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/handle/10665/330080, accessed 21 March 2021). A74/12 5 youth unemployment and rural economic development approaches adopted by UEMOA member countries. 21. There is a mismatch between the urgency of the health workforce agenda for education, skills and jobs, and the political and financial support provided by the major G20 economies. The capital and recurrent costs of education and employment in the health sector receive a small share of official development assistance to health, and no major development agency has linked its education and gender policies or thematic funding to “decent work” and jobs for women in the health sector. Financing, at the scale necessary to address decades of underinvestment, should be realigned around what is directly impactful for emergency preparedness and response, public health, primary health care and universal health coverage. In low-income and middle-income countries, this should commence with the absorption of unemployed doctors, nurses and other occupations to fill gaps in critical skills and jobs. The way forward 22. As per decision WHA73(15) and noting the necessity for all Member States to protect and invest in the health and care workforce, a proposed way forward is identified below. This will build on the results and collaborative partnerships of the five-year action plan to date, engaging new partners and donors to ensure that Member States have access to technical advice and the catalytic support required to develop a sustainable health and care workforce that is protected, empowered and resilient. (a) WHO, working with its partners ILO and OECD, to support the development of a renewed mandate, commitment and set of actions to drive forward a health and care workforce action plan and investment agenda that is relevant for 2022–2030. The action plan will continue to reflect the commitments of the High-Level Commission on Health Employment and Economic Growth to decent work, education and employment – particularly for women and youth – aligned with other global strategies, plans and tools for delivering primary health care, universal health coverage and health security.1 (b) WHO to initiate a Member State-led process engaging a coalition of stakeholders, including international financing institutions and philanthropic foundations, to drive the policy and investment agenda in the International Year of Health and Care Workers. A working group will in the period from June to September 2021 produce an evidence-based mandate, aligned with other global initiatives, that can massively accelerate investments in health workforce education, skills and jobs. The renewed mandate will be underpinned by measurable actions, timelines, expected results and resources to drive sustained long-term engagement and investment. (c) WHO to work with ILO and OECD on a financing instrument for the renewed mandate. The instrument should enable Member States to access targeted funding for the capital and recurrent expenditures for education and employment in the health sector, leveraging existing collaboration with international financing institutions including the European Investment Bank and the World Bank. It will build on the existing Working for Health Multi-Partner Trust Fund, thereby leveraging its governance and accountability structures. 1 Including the Global Action Plan for Healthy Lives and Well-being for All; Access to COVID-19 Tools (ACT) Accelerator; WHO Global Patient Safety Action Plan 2021–2030; UHC Compendium 2020; Quality health services: a planning guide (WHO 2020); United Nations Global Compact for Safe, Orderly and Regular Migration; Decent work and the 2030 Agenda for Sustainable Development (ILO 2017). A74/12 6 ACTION BY THE HEALTH ASSEMBLY 23. The Health Assembly is invited to consider this report and to provide further guidance on the proposed way forward. = = =