546269 research-article2014
RSH0010.1177/1757913914546269FeatureFeature
Feature
Universal health coverage and the public health workforce Universal health coverage is a major global public health concern, however the place of the public health workforce is often invisible in these discussions. This commentary will briefly review the universal health coverage and human resources for health agendas and the challenges in addressing the public health workforce. Universal health coverage (UHC), part of the post-2015 development agenda, is an aspiration widely shared across the world and promoted by numerous international organizations. In 2012 the United Nations General Assembly adopted a resolution for UHC, which urges governments to move towards ‘providing all people with access to affordable, quality healthcare services’. The World Health Organization (WHO), which has a leading role in supporting countries to respond to the challenge of UHC and monitors its implementation, describes global support for UHC as gathering momentum.1 Margaret Chan, Director-General of WHO has said: “I regard universal health coverage as the single most powerful concept that public health has to offer. It is inclusive. It unifies services and delivers them in a comprehensive and integrated way, based on primary health care”. One of the challenges of UHC is the global shortage of all types of health workers, which has been a concern for many countries and forms a central plank of the work of WHO and many other global and regional organizations such as the World Bank, Bill & Melinda Gates Foundation and the Clinton Foundation. WHO’s strategy on Human Resources for Health (HRH)2 seeks to ensure that all people have equitable access to an adequately trained, skilled and supportive health workforce, in order to attain the highest possible level of health. The Third Global Forum on HRH in Brazil in 2013 resulted in the bolstering of political commitments on HRH, based on technical evidence, in order to accelerate progress towards
UHC, and it began the process of developing a global strategy. These are crucial developments, but despite UHC being a major public health concern confronting the world and the significant global effort to address health workforce concerns, the place of the public health workforce seems invisible in these discussions. This commentary presents a brief review of the public health workforce in the context of the UHC and HRH agendas, together with a consideration of the opportunities for greater intersection, and therefore greater success.
delivery of individual health services. The monitoring indicators developed by WHO and the World Bank emphasize financial protection and impoverishment on the one hand, and service coverage for a variety of ‘vertical’ programmes, such as maternal and child health, on the other, albeit including some population-level health services.7 The financing and delivery of population-level health interventions seem to be largely sitting in the background, and the issue of public health system preparedness and public health system strengthening are largely absent from the discourse.
UNIVERSAL HEALTH COVERAGE UHC - which is not a new concept - has HUMAN RESOURCES FOR been broadly defined as all people having HEALTH access to needed service of appropriate The global HRH conversation has been quality without suffering financial concerned with addressing health worker hardship. The definition covers both migration, and promoting improved individual and population health services workforce planning and educational – including promotion, prevention, acute development at the national level. Labour treatment, rehabilitation and palliation. market studies are increasingly being UHC is consistent with the definition of undertaken as part of understanding the health in the WHO Constitution and the dynamics of health workforce recruitment Declaration of Alma Ata,3 and retention. However, this and has been more workstream has some recently articulated in the most countries Health Systems have a variety of gaps. It is largely focused on countries experiencing Knowledge Network of workplace HRH crisis - i.e. insufficient the Commission for problems, Social Determinants of including quality, numbers of health workers Health,4 and the World recruitment and to deliver healthcare. This is a good place to start, Health Reports on retention in but most countries have a Renewal of Primary Care5 primary care variety of workplace and Health Financing.6 settings problems, including quality, In practice, however, recruitment and retention the differing understandings of UHC have either led to in primary care settings, inflexible models of care or narrowly defined roles, or a focus on health insurance, or on
September 2014 Vol 134 No 5 l Perspectives in Public Health 245 Downloaded from rsh.sagepub.com at Freie Universitaet Berlin on May 1, 2015
Feature Secondly: what are the core public health competencies needed in the healthcare workforce to deliver on improved population health outcomes? High-income countries have also been considering this issue, particularly in the context of primary care and NCD prevention and control. To what extent should health workers providing individual clinical services also have knowledge and skills related to population health interventions (ranging from peer support to community development to policy advocacy)? To what extent should population health services be part and parcel of primary care service delivery? Should these health workers be considered part of the public health workforce? To the extent that UHC and HRH discourses are not addressing public health system preparedness, there is a third challenge of what workforce is core to public health preparedness in high, medium and low income countries alike. Like the issue of primary care, is it ensuring hospitals, labs, and primary care providers have the capabilities to undertake investigations, to control outbreaks and to manage disasters? Or does it also include the monitoring of sentinel events, development of community resilience, adoption of Public Health Workforce There are essentially two core challenges mitigation measures and planning for surge capacity? in bringing consideration of public health In high income countries such as workforce into the UHC and HRH Australia, successive discourses. The first, work on the public exemplified in other health workforce since papers in this issue, is what are the core the 1990s has been to definitional. public health consider this workforce What is the public competencies to include a specialist health workforce? Many needed in the workforce with high-income countries healthcare particular public health have been wrestling with workforce to skills and knowledge this issue for some years. deliver on as well as the general Is it a specialist role? Is it improved healthcare workforce defined around essential population health which has particular public health functions or outcomes? roles and skills to a particular set of deliver populationprogrammes/services? Is based health the Masters of Public interventions.8 In the former group would Health (MPH) a necessary qualification? Should it be licensed/accredited/ be epidemiologists, health promoters, registered? It is hard to see how environmental health practitioners for workforce planning be done if the example, while doctors and nurses workforce can’t be defined. would belong in the latter group. inadequate knowledge and skills to address emerging problems of noncommunicable disease (NCD) and aging. Another limitation is its emphasis on doctors and nurses, and to a lesser extent pharmacists and mid-level workers such as skilled birth attendants. There is also attention on community health workers as a way of improving primary health care, especially in rural areas - indeed, these have been part of the funding strategy by various vertical programmes to ensure there is delivery of services for tuberculosis, malaria, immunization, HIV/AIDS - but the conversation lacks sufficient consideration of the workforce requirements (including competencies as well as numbers) to deliver populationbased health services. These would include frontline service delivery (such as health promotion, environmental and occupational health) and the organization of such services (such as health policy, legislation, planning and financing). There is also little discussion about models of service delivery for population-based health services and the need for health care workers to develop awareness and skills in population health.
246 Perspectives in Public Health l September 2014 Vol 134 No 5 Downloaded from rsh.sagepub.com at Freie Universitaet Berlin on May 1, 2015
Some countries also consider nonhealth sector workforce whose work is seen as vital to contributing to population health improvement to be part of the wider public health workforce, even if these workers (such as architects, lawyers, teachers) would hardly consider themselves part of the public health workforce. Another approach taken more recently in Australia is to focus on the preventive health workforce.9 This approach has been more concerned about the delivery of NCD-related programmes in both community and primary care settings – interventions in tobacco control, obesity prevention, diabetes and hypertension prevention and management – than with those public health interventions focused on environmental and structural interventions at the societal level. In this construction, the preventive workforce includes groups such as health promoters, general practitioners, dieticians, community nurses and physiotherapists. Alternative approaches, some of which are described in this issue, seen particularly in the United States (US) but also expanding in Europe, is to ‘license’ public health professionals. The US has a long history of accrediting schools of public health and credentialing health educators, so credentialing at the individual level is perhaps a natural progression, albeit on a voluntary basis. Concurrently, there has been a proliferation of efforts in the US to develop competencies for various segments of the public health workforce, such as for global health and public health preparedness. In Europe, competencies in public health have been developed, for example in the UK, while competencies for accreditation of health promotion professionals in Europe has been developed under the auspices of the International Union for Health Promotion and Education.10 How public health and health promotion interrelate is, however, less well defined. In developing countries, these issues need attention, and appropriate and context-specific resolution. When resources are limited and health needs are great, what should be the balance
Feature of attention on knowledge and skill development in the health workforce? Should greater weight be given to public health in educating the general health workforce – for instance, should nurses and allied health personnel be part of the core public health workforce? What are the specialist public health knowledge and skills that should receive strongest emphasis – for instance, are planners and policy analysts more important than epidemiologists in order to assure allocative efficiency in the health system? Should all medical doctors be first trained in public health and preventive medicine?
Ways Forward There is clearly a need and scope to give greater consideration to the public health workforce in the global agendas for UHC and HRH. But what might be the most productive ways to do so? Firstly, it is important to engage with the UHC developments to emphasize the
importance of population health interventions, especially given equity and sustainability are at the core of its objectives. Universality means everyone. Population health interventions also mean everyone – reached especially through structural and environmental interventions. They cover more people than individual level interventions and can be more cost effective. Population-level interventions that are planned and budget financed are more likely to achieve sustainable and population health improvements than individual health services based on either opportunistic access or funded through insurance schemes. Secondly, it is important to articulate more precisely the place and the contribution of the various components of the public health workforce – in individual service delivery, in population health services and in the design of health systems. By doing so, it becomes more possible to identify and plan for public health workforce development including public health specialties, in the broader context of health workforce
planning, education, recruitment and retention. Thirdly, it is important to ensure that public health system strengthening becomes integral to the discourse and work on health system strengthening. Health system strengthening has focused more on the capacity to deliver individual health services than population health services. While a focus in many developing countries has been on primary health care, the concern has largely been on traditional vertical programmes, such as maternal and child health, immunization and TB. There is a need to make more explicit the core public health functions that need to be undertaken in all health systems, including public health preparedness, and ensure that an appropriately skilled workforce is available and able to perform these functions.
World Health Organization. Primary health care: now more than ever. WHO Report, 2008. Available online at: http://www.who.int/whr/2008/ whr08_en.pdf (Last accessed July 2014). 6. World Health Organization. Health systems financing: the path to universal coverage. WHO, 2010. Available online at: http://www. who.int/wht/2010/en/ (Last accessed July 2014). 7. World Health Organization and World Bank. Monitoring progress towards universal health coverage at country and global levels: a framework. WHO and World Bank, 2013. Available online at: http://www.who.int/ healthinfo/country_monitoring_evaluation/ UHC_WBG_DiscussionPaper_Dec2013.pdf (Last accessed July 2014). 8. National Public Health Partnership. Planning framework for the public health
workforce: discussion paper. National Public Health Partnership, 2002. Available online at: http://www.health.vic.gov.au/ archive/archive2014/nphp/publications/ wfpapers/wfplanning.pdf (Last accessed July 2014). 9. Human Capital Alliance. Audit of the preventive health workforce in Australia: final report of project findings. Human Capital Alliance, 2012. Available online at: http://www.health.vic.gov. au/archive/archive2014/nphp/publications/ wfpapers/wfplanning.pdf (Last accessed July 2014). 10. Barry, MM; Battel-Kirk, B; Davison, H; Dempsey, C; Parish, R; Schipperen, M; Speller, V; Zanden, van der, G; Zilnyk, A (2012) The CompHP Project Handbooks. Paris: International Union for Health Promotion and Education (IUHPE).
Vivian Lin Professor of Public Health La Trobe University, Melbourne
References 1.
World Health Organization. Universal health coverage. WHO, 2012. Available online at: http://www.who.int/universal_health_coverage/ un_resolution/en/ (Last accessed July 2014). 2. World Health Organization. Strategy of WHO Human Resources for Health 2010-2015. WHO, 2006. Available online at: http://www. who.int/hrh/strategy/en/ (Last accessed July 2014). 3. Alma-Ata USSR. International Conference on primary health care. Alma-Ata, 1978. Available online at: http://www.who.int/publications/ almaata_declaration_en.pdf (Last accessed July 2014). 4. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the CSDH, WHO, Geneva, 2008.
5.
September 2014 Vol 134 No 5 l Perspectives in Public Health 247 Downloaded from rsh.sagepub.com at Freie Universitaet Berlin on May 1, 2015
RSH0010.1177/1757913914546269FeatureFeature
Feature
Universal health coverage and the public health workforce Universal health coverage is a major global public health concern, however the place of the public health workforce is often invisible in these discussions. This commentary will briefly review the universal health coverage and human resources for health agendas and the challenges in addressing the public health workforce. Universal health coverage (UHC), part of the post-2015 development agenda, is an aspiration widely shared across the world and promoted by numerous international organizations. In 2012 the United Nations General Assembly adopted a resolution for UHC, which urges governments to move towards ‘providing all people with access to affordable, quality healthcare services’. The World Health Organization (WHO), which has a leading role in supporting countries to respond to the challenge of UHC and monitors its implementation, describes global support for UHC as gathering momentum.1 Margaret Chan, Director-General of WHO has said: “I regard universal health coverage as the single most powerful concept that public health has to offer. It is inclusive. It unifies services and delivers them in a comprehensive and integrated way, based on primary health care”. One of the challenges of UHC is the global shortage of all types of health workers, which has been a concern for many countries and forms a central plank of the work of WHO and many other global and regional organizations such as the World Bank, Bill & Melinda Gates Foundation and the Clinton Foundation. WHO’s strategy on Human Resources for Health (HRH)2 seeks to ensure that all people have equitable access to an adequately trained, skilled and supportive health workforce, in order to attain the highest possible level of health. The Third Global Forum on HRH in Brazil in 2013 resulted in the bolstering of political commitments on HRH, based on technical evidence, in order to accelerate progress towards
UHC, and it began the process of developing a global strategy. These are crucial developments, but despite UHC being a major public health concern confronting the world and the significant global effort to address health workforce concerns, the place of the public health workforce seems invisible in these discussions. This commentary presents a brief review of the public health workforce in the context of the UHC and HRH agendas, together with a consideration of the opportunities for greater intersection, and therefore greater success.
delivery of individual health services. The monitoring indicators developed by WHO and the World Bank emphasize financial protection and impoverishment on the one hand, and service coverage for a variety of ‘vertical’ programmes, such as maternal and child health, on the other, albeit including some population-level health services.7 The financing and delivery of population-level health interventions seem to be largely sitting in the background, and the issue of public health system preparedness and public health system strengthening are largely absent from the discourse.
UNIVERSAL HEALTH COVERAGE UHC - which is not a new concept - has HUMAN RESOURCES FOR been broadly defined as all people having HEALTH access to needed service of appropriate The global HRH conversation has been quality without suffering financial concerned with addressing health worker hardship. The definition covers both migration, and promoting improved individual and population health services workforce planning and educational – including promotion, prevention, acute development at the national level. Labour treatment, rehabilitation and palliation. market studies are increasingly being UHC is consistent with the definition of undertaken as part of understanding the health in the WHO Constitution and the dynamics of health workforce recruitment Declaration of Alma Ata,3 and retention. However, this and has been more workstream has some recently articulated in the most countries Health Systems have a variety of gaps. It is largely focused on countries experiencing Knowledge Network of workplace HRH crisis - i.e. insufficient the Commission for problems, Social Determinants of including quality, numbers of health workers Health,4 and the World recruitment and to deliver healthcare. This is a good place to start, Health Reports on retention in but most countries have a Renewal of Primary Care5 primary care variety of workplace and Health Financing.6 settings problems, including quality, In practice, however, recruitment and retention the differing understandings of UHC have either led to in primary care settings, inflexible models of care or narrowly defined roles, or a focus on health insurance, or on
September 2014 Vol 134 No 5 l Perspectives in Public Health 245 Downloaded from rsh.sagepub.com at Freie Universitaet Berlin on May 1, 2015
Feature Secondly: what are the core public health competencies needed in the healthcare workforce to deliver on improved population health outcomes? High-income countries have also been considering this issue, particularly in the context of primary care and NCD prevention and control. To what extent should health workers providing individual clinical services also have knowledge and skills related to population health interventions (ranging from peer support to community development to policy advocacy)? To what extent should population health services be part and parcel of primary care service delivery? Should these health workers be considered part of the public health workforce? To the extent that UHC and HRH discourses are not addressing public health system preparedness, there is a third challenge of what workforce is core to public health preparedness in high, medium and low income countries alike. Like the issue of primary care, is it ensuring hospitals, labs, and primary care providers have the capabilities to undertake investigations, to control outbreaks and to manage disasters? Or does it also include the monitoring of sentinel events, development of community resilience, adoption of Public Health Workforce There are essentially two core challenges mitigation measures and planning for surge capacity? in bringing consideration of public health In high income countries such as workforce into the UHC and HRH Australia, successive discourses. The first, work on the public exemplified in other health workforce since papers in this issue, is what are the core the 1990s has been to definitional. public health consider this workforce What is the public competencies to include a specialist health workforce? Many needed in the workforce with high-income countries healthcare particular public health have been wrestling with workforce to skills and knowledge this issue for some years. deliver on as well as the general Is it a specialist role? Is it improved healthcare workforce defined around essential population health which has particular public health functions or outcomes? roles and skills to a particular set of deliver populationprogrammes/services? Is based health the Masters of Public interventions.8 In the former group would Health (MPH) a necessary qualification? Should it be licensed/accredited/ be epidemiologists, health promoters, registered? It is hard to see how environmental health practitioners for workforce planning be done if the example, while doctors and nurses workforce can’t be defined. would belong in the latter group. inadequate knowledge and skills to address emerging problems of noncommunicable disease (NCD) and aging. Another limitation is its emphasis on doctors and nurses, and to a lesser extent pharmacists and mid-level workers such as skilled birth attendants. There is also attention on community health workers as a way of improving primary health care, especially in rural areas - indeed, these have been part of the funding strategy by various vertical programmes to ensure there is delivery of services for tuberculosis, malaria, immunization, HIV/AIDS - but the conversation lacks sufficient consideration of the workforce requirements (including competencies as well as numbers) to deliver populationbased health services. These would include frontline service delivery (such as health promotion, environmental and occupational health) and the organization of such services (such as health policy, legislation, planning and financing). There is also little discussion about models of service delivery for population-based health services and the need for health care workers to develop awareness and skills in population health.
246 Perspectives in Public Health l September 2014 Vol 134 No 5 Downloaded from rsh.sagepub.com at Freie Universitaet Berlin on May 1, 2015
Some countries also consider nonhealth sector workforce whose work is seen as vital to contributing to population health improvement to be part of the wider public health workforce, even if these workers (such as architects, lawyers, teachers) would hardly consider themselves part of the public health workforce. Another approach taken more recently in Australia is to focus on the preventive health workforce.9 This approach has been more concerned about the delivery of NCD-related programmes in both community and primary care settings – interventions in tobacco control, obesity prevention, diabetes and hypertension prevention and management – than with those public health interventions focused on environmental and structural interventions at the societal level. In this construction, the preventive workforce includes groups such as health promoters, general practitioners, dieticians, community nurses and physiotherapists. Alternative approaches, some of which are described in this issue, seen particularly in the United States (US) but also expanding in Europe, is to ‘license’ public health professionals. The US has a long history of accrediting schools of public health and credentialing health educators, so credentialing at the individual level is perhaps a natural progression, albeit on a voluntary basis. Concurrently, there has been a proliferation of efforts in the US to develop competencies for various segments of the public health workforce, such as for global health and public health preparedness. In Europe, competencies in public health have been developed, for example in the UK, while competencies for accreditation of health promotion professionals in Europe has been developed under the auspices of the International Union for Health Promotion and Education.10 How public health and health promotion interrelate is, however, less well defined. In developing countries, these issues need attention, and appropriate and context-specific resolution. When resources are limited and health needs are great, what should be the balance
Feature of attention on knowledge and skill development in the health workforce? Should greater weight be given to public health in educating the general health workforce – for instance, should nurses and allied health personnel be part of the core public health workforce? What are the specialist public health knowledge and skills that should receive strongest emphasis – for instance, are planners and policy analysts more important than epidemiologists in order to assure allocative efficiency in the health system? Should all medical doctors be first trained in public health and preventive medicine?
Ways Forward There is clearly a need and scope to give greater consideration to the public health workforce in the global agendas for UHC and HRH. But what might be the most productive ways to do so? Firstly, it is important to engage with the UHC developments to emphasize the
importance of population health interventions, especially given equity and sustainability are at the core of its objectives. Universality means everyone. Population health interventions also mean everyone – reached especially through structural and environmental interventions. They cover more people than individual level interventions and can be more cost effective. Population-level interventions that are planned and budget financed are more likely to achieve sustainable and population health improvements than individual health services based on either opportunistic access or funded through insurance schemes. Secondly, it is important to articulate more precisely the place and the contribution of the various components of the public health workforce – in individual service delivery, in population health services and in the design of health systems. By doing so, it becomes more possible to identify and plan for public health workforce development including public health specialties, in the broader context of health workforce
planning, education, recruitment and retention. Thirdly, it is important to ensure that public health system strengthening becomes integral to the discourse and work on health system strengthening. Health system strengthening has focused more on the capacity to deliver individual health services than population health services. While a focus in many developing countries has been on primary health care, the concern has largely been on traditional vertical programmes, such as maternal and child health, immunization and TB. There is a need to make more explicit the core public health functions that need to be undertaken in all health systems, including public health preparedness, and ensure that an appropriately skilled workforce is available and able to perform these functions.
World Health Organization. Primary health care: now more than ever. WHO Report, 2008. Available online at: http://www.who.int/whr/2008/ whr08_en.pdf (Last accessed July 2014). 6. World Health Organization. Health systems financing: the path to universal coverage. WHO, 2010. Available online at: http://www. who.int/wht/2010/en/ (Last accessed July 2014). 7. World Health Organization and World Bank. Monitoring progress towards universal health coverage at country and global levels: a framework. WHO and World Bank, 2013. Available online at: http://www.who.int/ healthinfo/country_monitoring_evaluation/ UHC_WBG_DiscussionPaper_Dec2013.pdf (Last accessed July 2014). 8. National Public Health Partnership. Planning framework for the public health
workforce: discussion paper. National Public Health Partnership, 2002. Available online at: http://www.health.vic.gov.au/ archive/archive2014/nphp/publications/ wfpapers/wfplanning.pdf (Last accessed July 2014). 9. Human Capital Alliance. Audit of the preventive health workforce in Australia: final report of project findings. Human Capital Alliance, 2012. Available online at: http://www.health.vic.gov. au/archive/archive2014/nphp/publications/ wfpapers/wfplanning.pdf (Last accessed July 2014). 10. Barry, MM; Battel-Kirk, B; Davison, H; Dempsey, C; Parish, R; Schipperen, M; Speller, V; Zanden, van der, G; Zilnyk, A (2012) The CompHP Project Handbooks. Paris: International Union for Health Promotion and Education (IUHPE).
Vivian Lin Professor of Public Health La Trobe University, Melbourne
References 1.
World Health Organization. Universal health coverage. WHO, 2012. Available online at: http://www.who.int/universal_health_coverage/ un_resolution/en/ (Last accessed July 2014). 2. World Health Organization. Strategy of WHO Human Resources for Health 2010-2015. WHO, 2006. Available online at: http://www. who.int/hrh/strategy/en/ (Last accessed July 2014). 3. Alma-Ata USSR. International Conference on primary health care. Alma-Ata, 1978. Available online at: http://www.who.int/publications/ almaata_declaration_en.pdf (Last accessed July 2014). 4. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the CSDH, WHO, Geneva, 2008.
5.
September 2014 Vol 134 No 5 l Perspectives in Public Health 247 Downloaded from rsh.sagepub.com at Freie Universitaet Berlin on May 1, 2015
