Towards universal health coverage: a health workforce fit for purpose and practice

The finality of universal health coverage (UHC) is to ensure that all people are able to access the quality health services they need without suffering undue financial hardship. Margaret Chan describes it as the ultimate expression of fairness.1 The italicized words above should therefore frame the starting point for a contemporary discourse on human resources for health in the post-2015 development agenda for health (2015–2030). UHC is an aspirational concept. It establishes what is to be achieved but says little on how to get there.2 However, the first step in accelerating progress towards UHC – building a health workforce that is both fit for purpose and fit to practice – is relatively simple. How does one go about it? By developing the competencies and regulatory frameworks needed to deliver quality care in accordance with the burden of disease and health priorities. The planning and implementation lens is ex ante: What health workforce do we need by 2030 to attain “effective coverage”3–7 of an agreed package of care that meets the needs of all people, be they rich or poor? This line of questioning, which is increasingly evident,8 generates the strategic intelligence to inform evidence-based decisions on human resources for health. Once need is quantified, a secondary but important policy consideration is pragmatism surrounding the available human and capital resources and fiscal space within national settings. Such pragmatism can inform the pace of acceleration towards UHC but should not undermine the initial workforce visioning process or the obligation of governments to deliver on the right to health.9 Existing thresholds for the required number of professional health workers (midwives, nurses and physicians) per 1000 population – 2.28 and 3.45 according to the World Health Organization (WHO) and the International Labour Organization, respectively10–12 – provide valuable references for translating need into indicative workforce requirements, but they should be considered part of the process of planning the workforce to meet the needs of the population rather than an absolute target in countries currently below these thresholds. To promote effective coverage and deliver services closer to the client, it is essential to further analyse the availability or supply of the workforce; its accessibility in spatial, temporal and financial terms; its acceptability to clients; and its quality, in terms of performance. This entails using internationally recognized standards to classify the different occupations in the health workforce; gaining a better understanding of the health labour market within a country; moving beyond counting health workers to assessing their full-time equivalent and available working time; and being more cognisant of the skill mix – and educational pathways – required for the workforce to become fit for purpose. To an extent, The Kampala declaration and agenda for global action and the WHO Global Code of Practice on the International Recruitment of Health Personnel offer existing global benchmarks.13,14 The accountability report from the meeting of the G8 held in June 2013 in Lough Erne, Northern Ireland, provides evidence that some countries are monitoring their recommended actions.15 However, the international community has yet to fully grasp the inherent value of these documents in fostering accountability. The 2013 progress report on the Global Code of Practice, for example, is a sober reminder that existing health workforce recommendations are not being implemented at scale in all WHO regions.16 A contemporary strategy on human resources for health, embedded within the post-2015 development agenda for health, is needed to accelerate progress towards UHC. Such a strategy should promote effective coverage with health services staffed by a workforce that is both fit for purpose and fit to practice. This requires an accompanying accountability and reporting mechanism not only for tracking the stock or density of the health workforce or the coverage of health interventions, but for collating disaggregated data on the availability, accessibility, acceptability and quality of the workforce to meet population needs, ensure the delivery of quality care and achieve fairness for all.