Why health workers count for achieving universal health coverage
Debates and discussions about universal health coverage (UHC) tend to focus on the need for more equitable and efficient health financing systems. Whilst health financing reform is a crucial part of the equation, other health system building blocks, including human resources for health, also need to be considered.
Each country will have a different approach to achieving UHC, but every government will need to ensure they have a strong health workforce if they are to be successful in achieving and sustaining UHC. As part of the Health Workers Count coalition, I have co-authored a briefing outlining some of the reasons why any effort to achieve UHC must consider the role of health workers.
In many countries, UHC is limited, at least in part, by shortages of appropriate health workers, particularly in remote and rural areas. India has stated, for example, that its Vision 2022 for UHC is dependent on the provision of “an adequate, equitably distributed, appropriately skilled and motivated health workforce”.
Health workers are often poorly supported, trained and equipped, under-paid and unequally distributed. Without sufficient numbers of appropriate health workers at the primary care level, it will not be possible to increase coverage of essential services. Even if medicines are readily available and provided free at the point of use, without health workers they will not reach the people who need them. Furthermore, if health workers do not have adequate training and supportive supervision, the quality of the services they can provide will be low which could lead to communities losing faith in their health system.
In many developing countries, health workers are concentrated in the capital city or wealthier urban areas because of better working and living conditions, leaving the populations most in need underserved. To expand coverage of services to those who need them most, health workers must be incentivised and supported to work in less desirable areas.
The role of frontline health workers should be maximised since they are the first and often only point of contact with the health system for millions of people. Given the right training, support, incentives and supervision, frontline health workers without professional qualifications (such as community health workers) can help to expand coverage of key services to otherwise underserved populations. For example, through Brazil’s successful Family Health Programme, 30,000 teams of health workers – comprising physicians, nurses, dentists and community agents – have expanded coverage of primary healthcare to the vast majority of the population, including the poorest and previously excluded groups.
Reducing out-of-pocket payments – an important aspect of many equitable health financing reforms – can have negative consequences for health workers if not implemented alongside broader efforts to strengthen health systems. Removing financial barriers to access helps to increase demand, however health workers often rely on formal and informal direct payments to supplement low salaries and cover the costs of running the facility. In such situations, health workers face the double burden of reduced income and increased workload. In order to retain and motivate health workers, and discourage them from charging informal fees, strategies to achieve UHC must ensure that health workers are adequately compensated and facilities are sufficiently resourced. In Sierra Leone, for example, preparations for the Free Health Care Initiative involved a review of the health workforce and a substantial increase in salaries.
Making better use of existing health workers could also reduce inefficiencies, another barrier to achieving UHC. Health workforces typically account for around half of national health expenditure so there are huge potential gains to be made from reducing inefficiencies and maximising the impact of existing health workers.
As more countries move towards UHC it is important that they recognise health workers as a key part of the solution and take action to train, deploy, equip and support a strong health workforce. All countries should develop and implement a costed, national health workforce plan with a special focus on covering the poorest and most excluded segments of society. Governments should also raise sufficient resources for health, with adequate resources allocated to long-term health worker training, recruitment, support and retention; develop more equitable health financing systems and minimise inefficiencies.
At the international level, discussions about a potential UN General Assembly Special Session on UHC in 2013 and making UHC a central tenet of the post-2015 framework should remember the role of health workers and other aspects of health system strengthening. Donors and development partners should increase financial and technical support to developing countries wishing to strengthen their health workforces and move towards UHC.
You can download the full briefing from Health Workers Count here.