Improving the resilience and workforce of health systems for women’s, children’s, and adolescents’ healthBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4148 (Published 14 September 2015) Cite this as: BMJ 2015;351:h4148
- James Campbell, executive director, Global Health Workforce Alliance, director, health workforce1,
- Giorgio Cometto, technical officer, Global Health Workforce Alliance1,
- Kumanan Rasanathan, senior health specialist2,
- Edward Kelley, director, Service Delivery and Safety1,
- Shamsuzzoha Syed, technical officer, Service Delivery and Safety1,
- Pascal Zurn, technical officer, Health Systems Evidence and Policy3,
- Luc de Bernis, senior maternal health adviser4,
- Zoe Matthews, consultant4,
- David Benton, chief executive officer5,
- Odile Frank, health and social services officer6,
- Andrea Nove, senior research associate7
- 1World Health Organization, Avenue Appia 20, 1207, Geneva, Switzerland
- 2Unicef, 3 United Nations Plaza, New York, USA
- 3Country Office in India, WHO, Indraprastha Estate, New Delhi, India
- 4United Nations Population Fund, New York, USA
- 5International Council of Nurses, 3 Place Jean-Marteau, 1201, Geneva, Switzerland
- 6Public Services International, BP 9, 01211 Ferney-Voltaire, CEDEX, FRANCE
- 7ICS Integrare, Barcelona, Spain
- Correspondence to: J Campbell
The United Nations’ first Every Woman Every Child strategy, Global Strategy for Women’s and Children’s Health, provided an impetus “to improve the health of hundreds of millions of women and children around the world and, in so doing, to improve the lives of all people.”1 The updated Global Strategy for Women’s, Children’s, and Adolescents’ Health calls for an even more ambitious agenda of expanding equitable coverage to a broader range of reproductive, maternal, newborn, child, and adolescent health services, as integral to the 2030 targets of the sustainable development goals.2
These goals cannot be realised by efforts that tackle only specific parts of the global strategy. Instead, an integrated approach is required, to include the complementary functions of stewardship, financing, workforce, supply chain, information systems, and service delivery.3 In this paper we highlight two core aspects that require urgent attention—building the resilience of health systems and ensuring sufficient human resources.
Our analysis is informed by lessons from countries that have made the most rapid progress on millennium development goals 4 (to reduce child mortality rates), 5 (to improve maternal health), and 6 (to combat HIV/AIDS, malaria, and other diseases) since 2000. In addition, we draw on the experiences of several countries in the recent outbreak of Ebola virus disease, new evidence on the workforce requirements for achieving universal health coverage,4 5 and the forthcoming WHO Global Strategy on Human Resources for Health: Workforce 20306 and WHO Global Strategy on People Centred and Integrated Health Care Services,7 which describe innovative ways to deliver services and organise workforces. These two strategies are the product of iterative and broad consultation processes, multiple literature reviews, and advice from expert groups. We cross checked key findings from these analyses with the contents of the revised Every Woman Every Child strategy.
Fragmentation of care and weak service delivery systems
Progress in achieving the millennium development goals has been substantive but uneven, with its equity, effectiveness, and sustainability being often undermined by lack of integration into national health systems. Even where efforts have been made to embed services at the community level, such as in the roll-out of integrated community case management of childhood illness programmes, a lack of full integration and stewardship by national health systems has hindered service use and sustainability.8 Disease specific approaches often fail to tackle the delivery of services for other diseases or to sustainably strengthen common delivery platforms.9 Despite both methodological and data limitations in the evidence,10 there are clear indications that working towards integrated service delivery can improve healthcare use and outcomes.11 The desire for focus on specific conditions is understandable, but efforts need to be aligned with and steered by national health systems and must be accompanied by deliberate attempts to create synergies with other priorities of the health system.
A further challenge is the insufficient resilience of many health systems to withstand shocks and adapt to changing needs.12 The recent outbreak of Ebola highlighted how progress in women’s, children’s, and adolescents’ health can be fragile in weak health systems (box 1).
Box 1: Weak health systems lack resilience
The resilience of a health system is its capacity to respond, adapt, and strengthen when exposed to a shock, such as a disease outbreak, natural disaster, or conflict. In weak health systems (such as those lacking core capacity in governance, financing, health workforce, or information systems), the ability of both the clinical and public health workforce to respond to planned and unplanned needs is limited, and gains can easily be reversed. In the most severe phases of the continuing Ebola outbreak in west Africa the needs of women for antenatal services, safe delivery, and postnatal care were not met. The capacity of the health system to continue delivery of essential health services and respond to the health crisis was limited, highlighting the need for substantial investment in, and improvement of, health systems.13
In Liberia skilled birth attendance fell from 52% to 38% and vaccination rates for measles and combined diphtheria, tetanus, and pertussis fell to 45% and 53%, respectively, during the outbreak. At the height of the outbreak, 64% of all Liberian health facilities were not operational (WHO, unpublished data). Sierra Leone reported that 21% fewer children received basic immunisation. In Guinea diphtheria, tetanus, and pertussis coverage dropped by 30% between 2013 and August 2014 (Ministere de la Santé, unpublished).
The health workforce, from the community level to specialist care, is critical in building resilient health systems. Progress in strengthening human resources for health currently falls short of population needs (box 2).14 15
Box 2: Future trends in the global health labour market
A projected shortfall of skilled health professionals (doctors, nurses, and midwives) of 10.1 million by 2030 has been identified, a challenge compounded by uneven geographic distribution.6 Sub-Saharan Africa is the most affected region in both absolute and relative terms, with a projected deficit of 3.7 million healthcare workers. Sustainable development goal 3.c appropriately calls for a substantial increase in health financing and in the recruitment, development, training, and retention of the health workforce in developing countries.16 At the same time, global demand for health workers will rise to 45 million additional professionals by 2030. A disparity exists, however, between population needs and market based demands, as those countries where basic health needs are the greatest have the fewest economic resources to create employment positions in the public health sector. The proposed sustainable development goals, which are implicit in the Every Woman Every Child strategy, will not be achieved without unprecedented international governance and solidarity, together with innovative national approaches to maximise the efficiency of available resources.
Disrupting the status quo
The Every Woman Every Child strategy should create a new agenda characterised by several key elements:
Approaches based on public health and social determinants, which reduce demand on costly clinical services, are critical components of a resilient health system,17 and improvements in the coverage of health services are linked to progress in sectors such as nutrition, water and sanitation, education, and transportation.
People centred, integrated health services are required throughout the life cycle, from early infant and child development, through adolescent, adult, and ageing populations.
Community engagement is needed to establish trust between patients and the health system and to empower patients to become active participants in, rather than passive recipients of, care.18 Health systems need to be deliberately designed to narrow equity gaps.
The health and social care workforce are people working in dynamic labour markets with responsibilities and rights—their opportunities for decent work and occupational health and safety are consistent with sustainable development goal 8, for decent work for all.
Finally, health systems are diverse, and the agenda needs to be adapted to different socioeconomic contexts—for example, enhanced capacity building and supportive investments from external sources will be needed in fragile states characterised by weak governance and leadership.
Leadership and integration at national level
All health programmes—whether funded by governments, development partners, civil society, or the private sector—must contribute to national priorities set by governments. To achieve this requires improved governance of health systems, better coordination between national and sub-national systems, and mobilisation of sufficient financing with better cash flow.19 Some of the countries that have made the greatest gains in maternal, child, and adolescent health are those where national governments have skilfully brokered international support for targeted interventions and integrated these initiatives into existing financing, workforce, and monitoring capacities within their national health systems.20 21 22 Other countries have improved their health outcomes by comprehensively strengthening their health workforce and using integrated platforms for delivery of care in the community.23 Promoting the exchange of knowledge and resources from these success stories, and using them as benchmarks, can accelerate progress in other countries.
The development of mechanisms to ensure continued delivery of essential health services during a health shock must include the capacity to cater to the special needs of women and children. The importance of putting people at the centre of delivery of health services was apparent in the ongoing Ebola outbreak—during the initial response, the early recovery phase, and long term planning for resilience. This entails renewed focus on sub-national delivery systems (particularly at community and district levels), on quality improvements, and on strengthening national disease surveillance and response (figure⇓).
Strengthening the workforce is a core element of this agenda, and it must encompass both short term measures—such as health and safety programmes, continuing training and supportive supervision, and community engagement—and recovery measures, such as increasing the fiscal space, adopting education strategies, developing locally appropriate incentive systems, and models of healthcare delivery that harness a more diverse and sustainable skills mix.
Prevention and control of infection are also important. Disease surveillance and information systems that use new technologies, such as mobile phones and rapid data collection forms, are the key to collecting geographically targeted data, which can be used for decision making and improvement of care.
Broader efforts at strengthening health system governance, including planning, monitoring, and accountability of policy makers, are also needed for effective health service delivery. Strengthening and building up these capacities are pre-conditions for effective health service delivery, especially in fragile states and contexts with weak governance, where they may also contribute to broader state building efforts.24
Improving the workforce
Optimising the competence and capacity of the health workforce can bring key services, such as contraception, closer to communities and improve coverage of key interventions to reduce maternal, neonatal, and fetal morbidity and mortality from obstetric complications. The “obstetric transition” of sustainable development goal 3.1 requires a health workforce that can provide obstetric and newborn services and access to family planning.25 Essential health and supporting services will need to be scaled up, particularly in the prevention of maternal and newborn deaths and stillbirths.26 Similarly, better distribution of skilled health professionals, with a particular focus on the midwifery workforce, will be needed.27 Despite international recommendations, midwives in many countries are not empowered to provide the basic functions of emergency obstetric care, including the use of vacuum extraction for difficult childbirth. New competencies will be needed to meet the additional service needs for youth and adolescent health, reproductive cancers, and to tackle the risk factors of childhood obesity.
Evidence has shown the potential for community based and mid-level practitioners to provide expanded coverage of other essential interventions for maternal, child, and adolescent health.28 29 Such practitioners must be adequately supported by health systems that enable their optimisation and sustainability (as in Bangladesh, Brazil, Ethiopia, Mozambique, Pakistan, Thailand, and others).30 31
Optimising the health workforce will also contribute to sustainable development goals 2 (end hunger, achieve food security and improved nutrition, and promote sustainable agriculture), 3 (ensure healthy lives and promote wellbeing for all at all ages), 4 (ensure inclusive and equitable quality education and promote lifelong opportunities for all), 5 (achieve gender equality and empower all women and girls), 6 (ensure availability and sustainable management of water and sanitation for all), and 8 (promote sustained, inclusive, and sustainable economic growth, full and productive employment, and decent work for all), as well as the updated Every Woman Every Child targets.32 33
Evidence from high income countries shows that despite a rise in unemployment in the manufacturing and construction sectors health sector employment has remained stable or grown during the recession.34 Emerging economies are undergoing an economic transition that will increase the health resource budget and a demographic transition that will see hundreds of millions of potential new entrants in the active workforce. These prospects create an unprecedented opportunity to design and implement health workforce strategies to tackle the gaps in equity and coverage faced by health systems, while also contributing to economic growth potential.35 The volume and growth of global health expenditures, which exceeded $6 trillion (£3.8 trillion; €5.5 trillion) a year by 2010, confirm that health is a sector with potential for substantial economic growth.36
To design and implement an enhanced workforce agenda, national institutions need to develop the capacities for collecting, collating, and analysing (public and private) workforce data and labour economics; leading short and long term health workforce planning and development; advocating for better employment and working conditions for health workers; designing, developing, and delivering enhanced pre-service and in-service education and training for health workers; supporting health professional associations; facilitating collaboration with, and regulation of, private sector educational institutions and health providers; overseeing the design of fair and effective performance management; and monitoring and evaluating human resources for health interventions.6
Much can be achieved if a global and comprehensive approach is implemented to tackle market failures and create the conditions for future health employment (particularly for women and young people) and economic growth. A measurement and accountability framework for the sustainable development goals can provide the foundations for new investments in national and sub-national health workforce information systems,6 and enable the implementation of a mechanism to standardise health workforce information across countries. Such a mechanism would be based on agreed health workforce indicators and could produce the information needed to facilitate health workforce planning and management.
The updated Every Woman Every Child strategy must place health systems at its heart, as their performance will decide success or failure for reproductive, maternal, newborn, child, and adolescent health in the next 15 years. Achieving the health goals of the new 2030 agenda will require augmented efforts to build integrated healthcare delivery systems, aligning market forces and population expectations for essential and universal care. This will require a radical transformation of implementation efforts at the country level. All programmes must be integrated into national health systems so they can be reconfigured to meet changing national needs. National and global governance must be overhauled to deliver a substantive scale-up of domestic public sector and international financing to meet systems and workforce needs. Health and social care should be recognised not just as rights but as opportunities for employment creation (particularly for young people and women) and economic growth. In addition, expanding the workforce is a good investment for implementation of the sustainable development goals. The existing systems and workforce need to be optimised, which can be made possible by stronger national institutions that are able to devise and implement more effective strategies. Capacity must be built at the local level to monitor health service delivery and inform policy change.
Securing the necessary political will, ensuring effective governance in countries, aligning the required efforts of different sectors and constituencies in society, and accountability are critical to achieving this ambitious vision. The updated Every Woman Every Child strategy could contribute to this agenda in several ways. Firstly, it could promote the development of international commitments, national plans, and investment decisions that recognise the centrality of building health system resilience and strengthening the health workforce. Secondly, it should include explicit targets and related accountability mechanisms that refer to the health systems and workforce needs. Finally, it should facilitate the adoption of funding approaches by related initiatives, such as the Global Financing Facility, that encourage long term investment in capital and recurrent costs for health systems.
Achieving the ambitious agenda of the global Every Woman Every Child strategy requires improved efforts at strengthening health systems, building their resilience, and tackling critical health workforce challenges
Targeted programmes relating to reproductive, maternal, newborn, child, and adolescent health should be led by countries and be integrated into national health systems
Governments should integrate international support for targeted interventions within their national health strategies and leverage these programmes into financing, workforce, and monitoring capacity across the system
The global strategy should consider the health system and workforce implications of its targets. It should promote commitments, investment, and accountability from both national and international sources that encourage sustainable investment in health systems and the health workforce
Cite this as: BMJ 2015;351:h4148
We thank Mwansa Nkowane (WHO), Laurence Codjia (WHO), Amani Siyam (WHO), Nadia Yakhelef (WHO), Metin Gulmezoglu (WHO), Edson Araujo (World Bank), Caroline Homer (University of Technology, Sydney), Emmanuel Makasa (Counsellor Health, Zambia Mission, Geneva), Francisco Pozo-Martin (ICS Integrare), Luisa Pettigrew (WONCA), Lynn P Freedman (Columbia University Medical Center), Paidamoyo Sharon Muyambo (Zimbabwe Mission, Geneva), Lola Dare (CHESTRAD), Jim Buchan (University of Technology, Sydney), Marie-Noel Brune Drisse (WHO), Margaret Murphy (University College Cork, Ireland), Carole Kenner (School of Nursing, Health and Exercise Science The College of New Jersey, USA), Jan-Willem Scheijgrond (Philips), Ryan Mulligan (World Vision), and Cindil Redick (Columbia University, USA). The insightful and constructive comments by the peer reviewers are also gratefully acknowledged.
Contributors and sources: We received input for this article from: an expert group (listed in the Acknowledgments section); a consultation in Abidjan, Cote d’Ivoire (13 February 2015); an event coordinated by WHO (Does the world have enough midwives? 23 February 2015); feedback from the Delhi Stakeholders Meeting (26-27 February 2015), and review from the Every Woman Every Child Steering Group. JC developed first draft of the article. GC led development of revisions of all subsequent drafts. KR contributed substantive technical contents on most sections of the document. EK and SS contributed contents particularly on health service delivery reforms and health systems resilience. PZ, LdB, ZM, DB, OF, and AN contributed significant contents on specific sections of the manuscript. Meet ICMJE criteria for authorship: JC, GC, KR, EK, SS, PZ, LdB, ZM, DB, OF, AN. JC is the guarantor.
Conflicts of interest: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.
Provenance and peer review: Not commissioned; externally peer reviewed.
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