Reprint from Nursing Leadership. 27(4) December 2014

Abstract

Context: “Promoting and protecting health is essential to human welfare and sustained economic and social development” (WHO 2010). This was recognized more than 30 years ago by the Alma-Ata Declaration signatories, who noted that Health for All would contribute to both a better quality of life, and global peace and security (WHO 1978). In continuing work to achieve this goal ofHealth for All, the contemporary global health agenda has focused on creating sustainable health systems that address universal health coverage (UHC) and the post-2015 sustainable development goals (SDGs), including non-communicable diseases, and health system financing. However, as noted in the Global Health Workforce Alliance (GHWA) report, A Universal Truth: No Health without a Workforce (2014), any aspiration to attain or sustain UHC will only be realized with a strong vibrant health workforce. 

Issue: There are long-standing, global human resources for health (HRH) shortages (Campbell et al. 2014; HRH Resource Center 2004). Based upon numerous international and national reports, governments around the world have focused on creating responsive and robust health workforces (WHO 2006, OECD 2008, GHWA 2012). Although there have been significant investments in health workforce planning, the progress to date has been thwarted by a mono-professional focus on the numbers of healthcare providers. While major countries such as China and India have seen improvements in the growth of their workforce, they, like many countries, continue to have significant HRH challenges, such as having sufficient numbers of qualified health workers who are equitably distributed geographically to meet local health needs (McPake 2013). What is required is HRH research and planning based upon the health needs of people and the combined competencies, skills and knowledge required to meet those needs all within specific health system and social contexts. Simply increasing the numbers has not addressed the systemic challenges; UHC and the SDGs require a discourse going beyond HRH shortages (GHWA and WHO 2014). 

Addressing both current and future HRH challenges requires multi-level planning with concurrent changes in policy, at the organizational level and in how care is delivered (GHWA 2012). Such multi-leveling planning requires partnership and collaboration across government sectors, with researchers and research users, with non-governmental agencies, with health and social system leaders, with communities and with healthcare providers. (GHWA and WHO 2014). 

Action: The nursing community believes that the time for a different narrative is now. This narrative would start by examining the health needs of people and health systems and then determining the HRH needs required to support these systems. To achieve this, hard questions would need to be discussed: 

• Why, in spite of the available evidence, do we keep envisioning a health system based upon the 19th century fragmented disease-based model? 
• What needs to be different? What needs to change to create this new model of care delivery? 
• What are the education systems required to educate health professionals to work in a new health system? 
• What are the legislative and regulatory frameworks and policies that need to be in place? 
• What are the HRH plans to support these systems? Within these plans, how do we attend to gender and women’s issues? 
• What data need to be collected and analyzed to monitor progress on an iterative and ongoing basis? 

In the context of national, regional and global agendas and plans, including WHO’s development of its Global Strategy on HRH, Health Workforce 2030, the following actions, issues and policy levers need to be considered.

• Dialogue and collaborative work needs to occur between all levels and sectors of the system since there are strong inter-dependencies between each level and concurrent strategies to support HRH are required. 
• Further, the dialogue needs to be supported by an understanding of and value for an integrated, primary healthcare system based on the health needs of people; where all health workers work together to optimize their professional scope. 
• The understanding and value of primary healthcare requires support for evidence informed inter-professional education and collaborative practice. This demands collaborative efforts among health and education ministries and systems. 
• All these changes require a recognition that we need to be in the business of health and not in the business of illness. This requires a balance between illness-focused, primarily hospital-based care and health promotion and wellness strategies in the community. 
• Policy and regulatory responses are required to enhance utilization and efficiencies in healthcare, and enable optimization of services. For example, by up-skilling current workers and allowing greater flexibility in determining the appropriate skills mix, over-reliance on task delegation should be avoided. Such approaches must ensure that health workers are enabled to be productive in safe and supportive workplace environments. 
• To address gender inequities and inequalities, women need to be at decision-making forums and policy-setting tables where they participate in and lead the health agenda. 
• As outlined in global and national reports, healthcare is growing economies and creating opportunities for employment. Therefore, we need to build in professional development opportunities to support career trajectories. Access to good jobs results in improved access to health and supports healthy families and communities. 
• HRH planning needs to be part of global and national development frameworks so that all factors impacting HRH are considered and integrated, multi-factorial and concomitant strategies are created and implemented. 
• This new narrative must be built on a broad definition and understanding of evidence that includes experiential knowledge and knowledge from non-peer-reviewed literature to randomized studies. 

Nurses around the world are essential healthcare team members who can provide quality and safe services with the support of regulatory frameworks. They have an essential role to play in macro, meso or micro system level planning approaches. For individual patients, nursing is involved in the processes of care used to identify needs, provide therapeutic interventions, education, advice, advocacy and physical, emotional and spiritual support. At the organizational and system levels nurses are informed by these same processes of care as health leaders, policy makers, educators and researchers who collaborate across health and social agencies to inform innovation and provide critical contributions to the efficient and effective health system transformation addressing and supporting the health and well-being of people. 

There are nine areas where nurses would make an essential contribution to this discussion on health systems and health workforce strengthening. 

1. Leading and supporting inter-professional and collaborative health provider education and practice 
2. Advocating for a paradigm and operational shift in healthcare that balances illness-focused care with population health 
3. Identifying and championing global and national strategies to address health workforce mal-distribution and migration 
4. Strengthening and diversifying primary healthcare by ensuring healthcare providers have the knowledge and skills needed to attend to people’s complex health and social needs 
5. Ensuring a strong nursing voice in all health and social system policy, development and planning dialogues 
6. Considering the influence of regulation and legislation on health system and HRH planning issues 
7. Designing and improving information infrastructures and data collection to support health system redesign and planning 
8. Creating and synthesizing the best evidence related to HRH and health systems research and evaluation 
9. Considering the influence of complex, ubiquitous social and gender issues such as the determinants of health, and inequality and inequity 

The International Council of Nurses, working with the nurses and health and social care colleagues around the world, is committed to leading innovative strategies to attend to the global, complex HRH and health system challenges. The goal is to support needs-based health system and HRH planning focused on supporting healthier and resilient communities. 

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