Odile Frank is President of the NGO Forum for Health. She has worked on health issues at the Organisation for Economic Cooperation and Development, the Population Council, the World Health Organization, the United Nations (as Chief, Social Integration in the Department for Social Development, DESA), the International Labour Organization (as Senior Research and Policy Adviser & Chief, Research and Policy Analysis Unit in the Global Programme on HIV/AIDS and the World of Work) and most recently at Public Services International (as the Health and Social Services Officer). She holds a Doctorate of Science from Harvard University, where she specialized in public health and Master’s degrees in Population Sciences and in Counselling Psychology. Odile Frank has authored numerous papers and articles in technical areas of international development. She is Secretary of the Geneva Global Health Hub.
High-Level Commission on Health Employment and Economic Growth
The High-Level Commission on Health Employment and Economic Growth presided by Presidents Hollande of France and Zuma of South Africa was set up in March 2016 by Ban Ki-moon, the now outgoing Secretary-General of the United Nations, and was charged to render its report by September 2016 at the opening of the General Assembly in New York. With the help of a group of experts and the Secretariats of the International Labour Organization, the World Health Organization and the Organisation for Economic Cooperation and Development, the Committee examined the link between the needed growth of the health sector and the fact that it is a sector that can generate employment where jobs are needed most – especially for women – to meet the twin objectives of decent jobs and job equity, in the context of the Sustainable Development Goals. The report contains 10 Recommendations that address both substantive objectives and the means to achieve them. This analysis focuses on expectations regarding the input of civil society that can be gleaned from the report, and concludes that a timid and largely auxiliary role is outlined for civil society.
By Odile Frank
The new development agenda of the United Nations for 2016-2030 – aptly entitled “Transforming our world” (1) – comprises 17 Sustainable Development Goals (SDGs). Although remarkably comprehensive, SDG3 for health (2) makes only one reference to the issue of increasing resources to achieve health, viz.: “substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries…”.
The reference points to a critical issue in achieving SDG3. All the objectives – to lower mortality from all causes, increase access to services, and strengthen national capacities in the face of global health risks – require a motivated, dedicated, trained health workforce that is ample to the task. Yet there is a global shortage of health workers even for the currently poor level of services that the SDGs are intended to improve. The recent outbreaks of EVD in West Africa illustrated drastic results of an inadequately deployed and equipped health workforce. The reasons for this – poor employment conditions and poor working conditions of health workers on one side, and tight or austere budgets and low political will to invest in health on the other – suggest that under current conditions the prospects to increase the health workforce and to achieve the SDG for health are poor without unwavering collective determination to turn the situation around.
Furthermore, SDG8 recognizes the need for better employment and working conditions for all workers. The goal to “promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all” stresses economic growth, economic productivity, productive activities and resource efficiency both through and for decent work for all.
In this context, Ban Ki-moon, United Nations Secretary-General, appointed a Commission on Health Employment and Economic Growth (3) on 2 March 2016, co-chaired by M. François Hollande, President of France, and Mr Jacob Zuma, President of South Africa. The three vice-chairs are Dr Margaret Chan, Director-General of the World Health Organization, Mr Angel Gurría, Secretary-General of the Organisation for Economic Co-operation and Development and Mr Guy Ryder, Director-General of the International Labour Organization (4).
Report of the Commission on Health Employment and Economic Growth
The Commission’s mandate rested on the link between the needed growth of the health sector and the fact that it could generate employment where jobs are needed most – especially for women – to meet the twin objectives of decent jobs and job equity. Projected growth is expected to create only about 40 million new health sector jobs by 2030 leaving a projected shortage of almost a third of all health workers needed – a shortfall of 18 million jobs – especially in the less affluent countries. The Commission – aided by an expert group (5) – was asked to address the creation of health sector jobs as a means to advance inclusive economic growth, especially for low and middle income countries (6).
The Commission was charged with working swiftly and handed in their report at a launch during the United Nations General Assembly on 20 September 2016.
The report of the Commission carries 10 recommendations, 6 of which concern goals, and 4 the means to achieve them. The 6 goals for health employment and economic growth are to (7):
- Stimulate investments in creating decent health sector jobs, particularly for women and youth…
- Maximize women’s economic participation and foster their empowerment…
- Scale up transformative, high-quality education and lifelong learning…
- Reform service models concentrated on hospital care and focus instead on prevention and on high-quality, people-centred primary and ambulatory care…
- Harness the power of cost-effective information and communication technologies…
- Ensure investment in skills development of national and international health workers in humanitarian settings and public health emergencies…Ensure the protection and security of all health workers and health facilities in all settings…
The 4 goals for means of implementation are to (7):
- Raise adequate funding from domestic and international sources, public and private where appropriate, and consider broad-based health financing reform…
- Promote intersectoral collaboration at national, regional and international levels; engage civil society, unions and other health workers’ organizations and the private sector…
- Advance international recognition of health workers’ qualifications to optimize skills use… and safeguard migrants’ rights
- Undertake robust research and analysis of health labour markets…to strengthen evidence, accountability and action
The Commission sees that the recommendations require “game-changing” actions to move away from the current state of affairs and to change the business-as-usual trajectory. Importantly, the Commission devised a plan for “immediate action” to be taken to implement the recommendations, giving the outlines of a roadmap to kick start the process, and urging the first actions to be taken between October 2016 and March 2018. The actions are listed below (8):
- Political leaders to bring the recommendations to pertinent decision-making fora at all levels and all stakeholders to make clear commitments towards implementing the recommendations
- The UN Secretary General to establish a global framework for SDG accountability, that must include the Commission’s recommendations
- Governments, which are urged to lead the reform of the health workforce, taking actions … engaging all stakeholder groups towards the achievement of universal health coverage, to work across sectors (health, education, employment, finance) on action plans, budgetary commitments for transformative education and skills, and job creation; and on setting up and reporting National Health Workforce Accounts
- International support and financial commitment to upgrade professional, technical and vocational education and training in low-income countries
- The ILO, OECD and WHO to draft 5-year plans to implement the 10 recommendations; advance existing commitments and push advocacy; set out interagency exchange of global health labour market data, hosted by the Global Health Observatory (at WHO); and develop a platform on international health worker mobility
ILO, OECD and WHO
As it stands, the Commission’s work is compatible with the Decent jobs agenda of ILO, and with the global workforce strategies being developed in the Health Workforce Department of the WHO and by the former Global Health Workforce Alliance. OECD is planning a ministerial health conference on 17 January 2017 addressing the topic “The Next Generation of Health Reforms” where one of the four main issues on the agenda will be “How to modernise the roles of health professionals” (9). The meeting is likely to be influenced by the outcome report of the Commission, especially as the OECD Health Ministerial follows OECD’s High-Level Policy Forum of 16 January whose theme is “Putting People at the Centre: The Future of Health”, an interactive set of discussions on integrating people-centred approaches in health systems that is planned to include health providers.
Clearly, 1 of the 4 means of implementation – intersectoral collaboration – rests on the engagement of civil society.
Reference to civil society entities is made in the forward by the three heads of organization (ILO, OECD, WHO) who say: “We look forward to working with UN agencies, financing institutions, governments, health professional associations, trade unions, civil society, academia, the private sector and other stakeholders to charter a bold shift in vision, policy and action, one that reflects and seizes the scale of opportunities for transformation that this Commission proposes” (bold added). Similarly, the Executive Summary concludes that “All recommendations require the upholding of rights, good governance, political commitment and intersectoral and multistakeholder cooperation“ (bold added). Another reference calls on governments to engage all stakeholder groups. Similarly, “All stakeholders”, a shorthand term that includes civil society, is included in the action directed at political leaders.
Yet, little is said about how civil society could or should be engaged. Civil society is not even singled out in the “Immediate Action” work plan to implement the recommendations, even though, as a “stakeholder” it is presumably expected to make “clear commitments” and to work on “independent accountability”.
In sum, references to civil society indicate that its role is important, but the impression given is that any contribution it can make depends on how it is consulted (“engaged”) and what is made by others of its input. Civil society is given a passive role, and no pro-active expectations are expressed. This is despite the fact that health workers globally are formally represented by well-known and sometimes high-profile entities of civil society – trade unions and professional associations – and that the most important stakeholder in respect of the health workforce is patients, who alone comprise the largest civil society group that exists, because it includes simply everybody.
For example, to enable change (chapter 3), the report says that “Political leadership is also needed to ensure that all stakeholder groups, including civil society, are actively engaged throughout the process”, whereas nothing is said about civil society’s own initiatives on the matter of its engagement, which is to be ensured by the political leadership (bold added) (see page 44).
Similarly, later in the same chapter, under partnerships and cooperation, it is stated that “Achieving a fit-for-purpose health workforce is an intersectoral pursuit… It requires interventions across the health labour market. Coherent and effective policy actions are best orchestrated across the finance, education, health, social welfare, labour and foreign affairs arms of the government through interministerial structures, coordination mechanisms and policy dialogues. These intersectoral structures and processes must engage the public and private sectors, civil society, trade unions, health worker associations, nongovernmental organizations, regulatory bodies and education and training institutions” (bold added) (see page 48). This text leaves quite open whether the involvement of civil society is before or after the “best orchestrated” approach to effective policy action.
On the same page, it can be argued that civil society appears as an afterthought in: “As these examples demonstrate, successful implementation of the Commission’s recommendations will depend in great part on the strength of the intersectoral engagement and actions of stakeholders—including civil society and health workers’ organizations—at national and global levels” (see page 48). In this context the overall recommendation among other things to “engage civil society, unions and other health workers’ organizations and the private sector” gives the appearance of quite passive engagement, waiting to be called on (bold added) (see page 49).
The explanatory text for goal 10 (for data, information and accountability) is even clearer in defining the place of civil society, making clear that civil society entities are not among the “key actors” but are among those charged with the role of holding the key actors accountable: “Finally, the Commission recognizes that the success of global movements and initiatives is often influenced by the strength of mechanisms to hold key actors accountable in the development and implementation process; we particularly note the important roles that non-state actors will play, including unions, professional bodies, civil society and academics, among others” (bold added) (see page 53).
Yet civil society entities, in particular trade unions and professional associations, have been proactive for a long time in proposing means to improve the quality and quantity of the global health workforce, a fact mentioned in a few places in the report (see page 34, for example), but that has no impact on the structure of the report, nor the architecture of the recommendations. Their approaches are not always in harmony with those of policy-makers and their employers, but peace does not reign either between the “key” stakeholders.
Furthermore, it is highly regrettable that in a 70-page report, the problem of the occupational health and safety of health workers, a substantial issue, is little mentioned – in a paragraph and an insert (Box 5) on page 31 – and that workers’ rights (excluding women’s rights that are more elaborated) are mentioned only on pages 31 and 32.
It seems to us that the Commission should have investigated the proposals emerging from the civil society entities with a clear interest in the global health workforce. There is substantial literature on the topic, both academic and political. Such an investigation would have allowed the Commission to provide a place and mandate for the proactive engagement of civil society entities that are working for health and growth and to include their views on how best to invest in the health workforce.
- See http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E
- Sustainable Goal 3.c
- See http://apps.who.int/iris/bitstream/10665/250047/1/9789241511308-eng.pdf?ua=1 accessed on 21 September 2016.
- See http://www.who.int/hrh/com-heeg/en/ and http://www.ilo.ch/global/about-the-ilo/newsroom/news/WCMS_462721/lang–en/index.htm
- See the terms of reference for the Expert group at http://www.who.int/hrh/com-heeg/ComHEEG-expert-group-TORsEN.pdf?ua=1
- The Commission was asked to 1. Recommend multi-sector responses and institutional reforms to develop human resource capacity to progress towards Universal Health Coverage (UHC); 2. Determine innovative sources of financing and conditions to maximize returns from investments in health employment; 3. Analyse the risks of global and regional imbalances and unequal distribution of health workers and assess the effects of international mobility; and 4. Generate the political commitment from government and key partners to support implementation of the Commission’s proposed action. See the terms of reference of the Commission at http://www.who.int/hrh/com-heeg/en/ and http://www.who.int/hrh/com-heeg/ComHEEG_TORs_fv.pdf?ua=1
- Key words are shown in bold and text is abbreviated.
- Key actors shown in bold.
- See http://www.oecd.org/health/ministerial/
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