Ensuring Accountability on Health Workforce Targets Key points and G8 proposed communiqué language June 2008 The world is facing a crisis in the health workforce, and the G8 is facing a crisis with respect to their own accountability to their health commitments. Given that the health workforce crisis is a major constraint to achieving the MDGs and other G8 endorsed health goals and given the importance of increased accountability, it is crucial that the 2008 G8 summit make a major and targeted commitment on the health workforce, which should in turn feed into the September 2008 UN summit on the MDGs. Several members of the G81 have expressed interest in a G8 health workforce target based on the WHO minimum threshold of 2.3 doctors, nurses, and midwives per 1,000 population, which, when taking into account the need for other health workers for a total of at least 4.1 health workers per 1,000 population, would require recruiting, educating, and retaining more than an additional 1.5 million health workers in Africa.2 Japan has committed to training at 100,000 new health workers over the next five years, and the United States and United Kingdom have pledged support for improving health worker coverage levels in Ethiopia, Kenya, Mozambique, and Kenya. The commitment Drawing on the principles below, the G8 should commit as follows: We will support all developing countries in achieving, as soon as feasible as part of a comprehensive approach to health workforce and system strengthening, the WHO goal on minimum health worker density of at least 4.1 health workers per 1,000 population, including at least 2.3 doctors, nurses, and midwives per 1,000 population. We commit to an increase of at least an additional 1.5 million health workers in Africa by 2015,3 including at least 600,000 additional health workers by 2012. We will take responsibility for mobilizing all needed financial and technical support to enable all countries to develop, by the end of 2009, comprehensive, costed national health workforce plans, linked to national health sector strategies, to develop and sustain an equitably distributed health workforce in the numbers and with the skills and support required to meet health needs, goals, and commitments.4
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In their April 17, 2008, announcement, the United States and United Kingdom specifically called on the G8 and others to work towards the WHO minimum threshold. The TICAD Action Plan released May 30, 2008, also recognized the need to achieve this threshold. 2 World Health Organization, World Health Report 2006 (2006), at 11-13. WHO estimates that there are approximately 1.8 health workers for every 1.0 doctors, nurses, and midwife, hence the 2.3/1,000 target translates into just over 4.1 total health workers per 1,000 population. This is an understatement of actual need as this figure does not include community health workers. 3 We will also support countries in other regions of the world to overcome their critical health worker shortages by 2015. WHO estimates that critical shortages outside of Africa total 2.8 million health workers, including a shortage of approximately 2.1 million in Asian countries. 4 These goals and commitments include achieving the MDGs by 2015, universal access to HIV/AIDS treatment, care, prevention, and support by 2010, and universal access to essential health services by 2015.
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To accomplish these goals, we will provide a new $4-5 billion for immediate measures (20082009) to educate, train, retain, equip, and otherwise support health care workers in Africa, as well as additional funds for developing countries outside of Africa.5 We will follow this with increasing investments in the form of additional long-term, predictable, and adequate funding as needed to enable, in combination with increased domestic financing for health including progress towards achieving the Abuja commitment, the full implementation of needs-based, costed national health workforce plans covering areas including health worker education and training, recruitment and employment, management and leadership, equitable deployment, retention, and support. We recognize that many countries will require long-term support for the health workforce and health generally, and commit to the long-term sustainability of our own funding. We will develop a cost-sharing strategy by the end of the Japanese G8 presidency. We will provide comprehensive reviews of progress towards these goals in 2010, 2013, and 2015. We will also report annually on progress, including on amounts and types of funding, such as for pre-service education, in-service training, retention, management, and equitable deployment, and on types of health workers being trained and supported. This proposed G8 commitment is based on the following principles: Targets and timelines The G8 should set time-bound targets on health workforce strengthening. This is needed to: o Establish G8 accountability to health workforce needs to meet MDGs and other commitments; o Support African an other developing countries in charting course to developing workforce needed to meet MDGs and other commitments; and o Catalyze immediate and urgently needed health workforce strengthening activities. To maximize the goals of ensuring accountability to commitments and ensuring an effective response to this complex crisis, there should be two targets. 1. A numerical workforce target. This should include both national health workforce density figure – a total of 4.1 health workers per 1,000 population, including 2.3 doctors, nurses, and midwives per 1,000 population – and an Africa-wide figure of an additional 1.5 million health workers. These targets will both ensure accountability to progress in every country as well as overall progress at a continental level. While the G8 may give particular focus to the health worker shortage in Africa, where the shortages are most severe, it must also recognize that critical health worker shortages exist in other regions of the world, including shortages of more than 2 million health workers in Asian countries, and support efforts to overcome these shortages as well. Any target should recognize the need for scaling up all cadres of health workers, with the mix of health workers determined by each country’s epidemiological profile and other factors. A 1.5 million target should include a deadline of 2015, in line with the MDGs and putting Africa on track for the 2 million or more additional health workers it
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We will determine which countries will contribute what funds by the UN MDG meeting in September.
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needs by 2020.6 A deadline for 2.3/1,000 or 4.1/1,000 creates additional challenges due to significant country diversity with respect to current workforce density, but should be accomplished as soon as feasible within a comprehensive approach to strengthening the health workforce and overall health systems. 2. A target based on the urgent need for comprehensive, costed national health workforce strategies aimed at achieving health goals and commitments. The Global Health Workforce Alliance’s (GHWA) Agenda for Global Action recognizes that all countries need such plans, which address not only numbers, but also actions needed to ensure that health workers are deployed where they are needed with the skills (including management as well as clinical and leadership skills) and support that they need to do their job effectively. The target should be for all developing countries (most urgently but not only the 57 [36 in Africa] that WHO has identified as having health worker crises) to have such plans, and for all plans to have the resources required for full implementation. Plans should be developed by no later than end 2009, and designed to meet timebound health goals including universal access to HIV/AIDS prevention, care, treatment, and support by 2010, the MDGs by 2015, and universal access to essential health services by 2015.7 Needs-based: The precise number and mix of health workers needed, the skills they require, and health workforce strategy overall, will be particular to each country. The plans that the G8 supports, and the G8 level of support, should be needs-based so as to achieve G8 and national government health commitments and obligations. Comprehensive: The G8’s health worker commitment should support a comprehensive approach to health workforce strengthening, including but not limited to training (also retention, equitable distribution, management, etc). It should also be linked to broader health system improvements and planning. Funding: WHO estimates that meeting health workforce needs will require at least $1020 per capita in new investments,8 translated into an annual need of at least $7 billion and possibly more than $14 billion in sub-Saharan Africa alone by 2015. A significant portion of this funding will need to come from international partners, especially the G8. The G8 should mobilize, benchmark, and measure funding progress based on evolving WHO and in-country estimates, and should divvy up funding responsibilities among G8 countries. Funding should be provided on a long-term and predictable basis to permit payment of recurrent health workforce costs. The G8 should recognize that many
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Due to population growth rates reported in the according to the Global Health Workforce Alliance’s Education Task Force report, achieving the 4.1/1,000 density will require more than 1.8 million additional health workers by 2015. Taking into account additional population growth, the total additional workforce need in Africa will be approximately 2 million by 2020. 7 The AU health ministers committed to universal access to prevention, care, and treatment based on an essential health package. Gaborone Declaration on a Roadmap Towards Universal Access to Prevention, Treatment and Care, African Union 2nd Ordinary Session of the Conference of African Health Ministers, Gaborone, Botswana, Oct. 10-14, 2005. Available at: http://www.africaunion.org/root/au/conferences/past/2006/may/summit/doc/GABORONE_DECLARATION.pdf. 8 World Health Organization, World Health Report 2006 (2006), at 13-14 .
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developing countries will require long-term support for the health workforce and health generally, and commit to the long-term sustainability of their funds.9 The G8 should provide an immediate infusion of funds. GHWA’s Scaling Up Education and Training Task Force estimated pre-service training needs in Africa at more than $2.6 billion annually over the next ten years.10 WHO’s estimates on educating, employing, and retaining health workers indicate a 2009 need of more than $6 billion. In light of these estimates, the G8 should commit to a minimum of $4-5 billion for health workforce strengthening in Africa (in addition to resources for in-service training) as a down payment through 2009, additional funds for other regions, and should plan for even greater long-term funding in the future based on financing gaps in national health workforce plans. This funding is needed to contribute to achieving existing health goals and obligations, and must be in addition to and not instead of the significant increased investments needed to fight AIDS, improve child and maternal health, address the food crisis, and to achieve other health and development objectives. Benchmarking and reporting: Clear benchmarks, timetable, and division of responsibility among G8 members are needed to keep the initiative on track. Benchmarks must be consistent with achieving commitments, and should include policy and institutional benchmarks, related for example to building educational capacity. Progress should be reported at least annually, and must be public and transparent, as should be national health workforce plans, their costs and funding levels, and progress in implementation. Reporting on health workforce financing should be broken into categories, wherever possible including types of health worker and whether training is to expand pre-service training capacity or is specific to a particular health condition. One benchmark should be near-term progress on overcoming the shortage of health workers, such as at least 600,000-700,000 additional health workers in Africa by 2012. Along with annual progress reports, the G8 should commit to comprehensive reviews of progress in 2010 (after all countries should have costed health workforce plans and the target for universal access to HIV/AIDS prevention, care, and treatment), 2013 (two years before the MDG target date), and 2015 (consistent with the MDGs).
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See, e.g., Keizo Takemi et al., Global Health, Human Security, and Japan’s Contributions (2008), at 12-13. See the Report of the Global Health Workforce Alliance Task Force for Scaling Up Education and Training for Health Workers, Scaling Up, Saving Lives (2008), at 73.
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