Tracing deficits and challenges in UHC and access
Using health sector employment, particularly the SAD, as a tracer for UHC discloses the most important gaps and challenges in health protection coverage and access to health care:
– the quantitative deficit in numbers of health workers needed to achieve UHC at the global, regional and national levels;
– the share of the population lacking health protection and access to care due to gaps in health sector employment at the global, regional and national levels; and
– the extent of inequities in health care access of populations living in countries with different income and poverty levels as well as with regard to rural/urban disparities.
Based on the estimates, we conclude that the global, regional, national and subnational gaps in health sector employment weaken the availability, affordability, accessibility and quality of health care services and result in access barriers and impoverishment, particularly in rural areas. Further, social outcomes of health worker shortages point to the fact that related UHC gaps can be considered as drivers of health inequities. In addition, the SAD allows concluding that non-addressing gaps in health sector employment result in higher mortality and increased economic costs of ill health.
The results provided inform policies aiming at achieving UHC in the context of SPFs on qualitative and quantitative impacts of (not) realizing the right to health of the population. However, the estimates presented should be complemented by additional analyses on the needed skill mix of the health workforce as well as a full assessment based on the AAAQ criteria. This requires taking further aspects and indicators into account, mainly revealing gaps in legal coverage and financing deficits, as well as deficits in the affordability of services and financial protection due to OOP.
Directing investments towards areas of high impact
The estimates presented identify areas where investments in higher health sector employment – if embedded in UHC/SPF policies – could achieve the greatest impacts and returns in terms of social, health and economic outcomes.
This is particularly the case in low-income countries of Africa and Asia and globally in rural areas. It would be the most rewarding to expand health protection coverage and develop inclusive approaches focusing on effective access to health care in these countries. Such investments have the potential to:
realize human rights to health and social security
increase equitable access to health care and thus equity in health
reduce poverty and impoverishment
contribute to economic growth
sustain development by increased employment and productivity
result in social peace, social justice and cohesion.
Revealing the necessity for aligned multi-sectoral policies for progress towards UHC in SPFs
The results presented reveal the complexity and multiple dimensions involved in achieving UHC and in meeting the AAAQ criteria. They also reflect the need for specific policies both within and beyond the health sector.
Developing and implementing inclusive legislation on UHC within SPFs is a prerequisite that is beneficial for progress in developing the health workforce. Consequently, vertical health funding focusing on, for example, one specific disease, is less conducive than overall health system development.
In addition, focusing on enabling labour market policies is crucial. While governments do not have full control of labour markets for health workers, it is important to ensure that regulations aiming at equity in access to at least essential health care are in place. Thus, governments should ensure that health sector employment is not guided by fiscal constraints and improve the distribution of the health workforce in rural and urban areas. Further, improved international cooperation in the area of migration of health workers should be considered.
Likewise, investments in training, skill development and employment conditions of health workers, including adequate wages and incentives as well as enabling working conditions ranging from occupational safety and health to part-time work, are of key importance. This concerns particularly employment in the public sector if working conditions are less attractive than in the private sector. Besides policies that increase retention rates due to better working conditions, it may also be necessary to regulate the private sector with a view to ensure equity in access .
Further, best use of skills is important so as to ensure services of highest quality as well as the most efficient and effective performance of the scarce health workforce. This requires better matching health and social protection schemes and systems, related institutions and financing mechanisms as well as redefining boundaries and shifting responsibilities of health, social and domestic workers as well as family carers, for example, in cases of long-term care.
Finally, achieving sustainability and maximizing the impact of investments require the alignment and coordination of health, social, economic and developmental polices in order to alleviate poverty and to transform informal labour markets and other informalities that negatively impact. Thus, health policies need to be embedded in broader social (protection) policies. At the national level, this requires the development and implementation of inclusive legislation on Social Protection Floors providing financial protection and access to affordable quality health services that are available. At the global level, the post-2015 agenda needs to focus on closing deficits in the health workforce to achieve UHC in the context of SPFs.