COVID-19 and human resources for health: analysis of planning, policy responses and actions in Latin American and Caribbean countries

Abstract

Background

The COVID-19 pandemic led to worldwide health service disruptions, due mainly to insufficient staff availability. To gain insight into policy responses and engage with policy-makers, the World Health Organization (WHO) developed a global approach to assess and measure the impact of COVID-19 on the health workforce. As part of this, WHO, together with the Pan American Health Organization (PAHO), supported an impact analysis of COVID-19 on health workers and policy responses, through country case studies in Latin America and the Caribbean (LAC).

Methods

We sought to identify lessons learned from policies on human resources for health (HRH) during health emergencies, to improve HRH readiness. First, we performed a rapid literature review for information-gathering. Second, we used the WHO interim guidance and impact measurement framework for COVID-19 and HRH to systematically organize that information. Finally, we used the Health Labour Market Framework to guide the content analysis on COVID-19 response in eight LAC countries and identify lessons learned to improve HRH readiness.

Results

Planning and implementing the COVID-19 response required strengthening HRH governance and HRH data and information systems. The results suggest two main aspects for HRH governance crucial to enabling an agile response: (1) aligning objectives among ministries to define and produce regulation and policy actions; and (2) agreeing on the strategy for HRH management between the public and private sectors, and between central and local governments. We identified three areas for improvement: (a) HRH information systems; (b) methodologies to estimate HRH needs; and (c) teams to analyse information for decision-making. Three key actions were identified during countries monitored, reviewed, and updated their response stages: (i) strengthening response through primary health care; (ii); planning HRH needs to implement the vaccination plan; and (iii) securing long-term HRH availability.

Conclusion

Countries coordinated and articulated with different stakeholders to align objectives, allocate resources, and agree on policy actions to implement the COVID-19 response. Data and information for HRH preparedness and implementation were key in enabling an agile COVID-19 response and are key areas to explore for improved pandemic preparedness.

Introduction

The COVID-19 pandemic has strongly impacted population health and put pressure on the entire health system¹ [1]. It led to health service disruptions around the world, due mainly to insufficient staff availability² [2]. COVID-19 has exposed health workers to infection, fatigue, occupational burnout, stress, harassment and physical and psychological violence. Efforts have been made to assess the pandemic’s direct impact on human resources for health (HRH). However, global estimates of COVID-19 infections and deaths among HRH tend to suggest that official reporting mechanisms do not capture the full scale of this impact [3].³

The pandemic has emphasized such HRH concerns as shortage and maldistribution as well as inadequate payment and decent working conditions, e.g., lack of contract stability. This added strain to the health system deepened any existing staff unavailability, affecting both teamwork and health workers’ mental health.⁴ Additionally, it has highlighted insufficiencies vis-à-vis data and information systems, while demonstrating the importance of data science in planning and reviewing the COVID-19 response related to HRH issues. However, the COVID-19 pandemic also has led to identifying ways to rapidly recruit, train, and protect the health workforce. This has led countries to use various mechanisms to plan and respond to COVID-19 from the HRH perspective [4,5,6] .

To address HRH-related COVID-19 challenges, the World Health Organization (WHO) developed a global approach to better assess and measure the impact of COVID-19 on HRH, to gain insight into management and policy responses as well as engagement with policy-makers. Thus, WHO developed an interim guidance on HRH policy and management in the context of the COVID-19 pandemic response [7] as well as a standardized impact measurement framework [8]. Additionally, living systematic reviews were undertaken, aimed at gathering information and analytics on health and care workers in the context of COVID-19. Alongside this process, health workforce intelligence related to COVID-19 was collected from open sources to complement the reviews. All the information collected on COVID-19 and HRH resulted in a World Health Assembly resolution, namely the Global health and care worker compact [9], which provides recommendations on how to protect health workers, safeguard their rights, and promote and ensure decent work. The overall aim was to support policy dialogue and advocacy opportunities.

This paper constitutes an effort to build on the International Year of Health and Care Workers (2021) and the strategic objectives of the Global strategy on human resources for health [10], aiming to strengthen support to countries as they design and implement strategies addressing health workers’ problems during COVID-19. Thus, WHO—together with two of its Regional Offices, the Pan American Health Organization (PAHO) and the WHO Regional Office for Africa (AFRO)—have supported COVID-19 impact analyses regarding health workers and policy responses by developing case studies from selected countries. These use a standardized methodology based on WHO interim guidance [7], the standardized impact measurement framework [8], and the Health Labour Market Framework [10, 11].

Gaining better insight into the policy response to COVID-19 is crucial for addressing the challenges ensuing from COVID-19. Nonetheless, as countries attempt to do so, there remains a lack of systematic knowledge on mechanisms and policies adopted by countries from different geographic areas and institutional governance to address HRH challenges. This paper is aimed at identifying lessons learned on HRH to better address health emergencies and build improved post-pandemic health systems. We do this through a secondary analysis of findings from the two sub-regional reports on eight countries of Latin America and the Caribbean.

The paper is organized as follows: the first section summarizes the methods used to develop the analysis. The second presents the mechanisms and policy responses adopted during the COVID-19 pandemic response, as analysed across the preparedness, implementation, and monitoring/updating phases. The final section presents lessons learned and concluding remarks.

Method

We adopted a multi-pronged approach for this paper. First, we conducted a rapid literature review on the background material for the case studies. Second, to systematically organize that information, we used the WHO interim guidance [7] and impact measurement framework for COVID-19 and HRH [8]. Finally, we used the HLM framework to analyse the information [11].

We carried out our literature review in 2020 and 2021, focusing on reports, grey literature and desk review of policies adopted during the pandemic, obtained from ministries of health (MoHs) and service delivery agencies; review of health information systems (HIS) and national human resource information systems (HRISs); and surveillance databases for data on HRH infections. The details have been published in the The impact of COVID-19 on human resources for health and policy response: the case of Plurinational State of Bolivia, Chile, Colombia, Ecuador and Peru [12].⁵ The present study adds three Caribbean countries (Belize, Grenada and Jamaica) [13].⁶ The data and information reported spans the period between March 2020 and April 2021. In this study, we focused on countries from the PAHO Region (i.e. the Americas) where the reports and background material on the selected countries⁷ systematically followed the WHO interim guidance [7]. Additionally, the countries participating in the reports are grouped into sub-regions developing common HRH-related policies where they are also part of sub-regional organizations like the Andean Health Agency/Hipólito Unanue Agreement (Organismo Andino de Salud–Acuerdo Hipólito Unanue) (ORAS-CONHU) and the Caribbean Community (CARICOM).

We used the domains listed in the guidelines from the WHO interim guidance [7], as well as the multidimensional factors affecting HRH listed in the standardized impact measurement framework [8]. This enabled us to organize the information on HRH policy response during COVID-19 in the eight Latin American and Caribbean countries around the three response pillars supporting health emergencies [14]: 1 workforce readiness in preparedness, 2 implementation; and 3 monitoring/updating the response.

We used the HLM framework to carry out the content analysis of the background documents and information on HRH response. This enabled us to understand mismatches and market failures in the health labour market (HLM) and thus identify and define policies and actions to build HRH readiness that currently guide the discussion on policy dialogue. For the Caribbean subregion, we achieved this in the HRH task force sessions; and for the Andean countries, through meetings and webinars held between 2021 and 2022. The outcome of these discussions led to policy briefs and identification of key elements strengthening HRH. We integrated the information into this paper in the form of challenges and actions identified to improve HRH in different areas of the three pillars to support improved response during health emergencies.

HRH in the context of the response to health emergencies

In this section, we discuss key HRH strategies used by countries during the COVID-19 policy response and connect them to each pillar supporting health emergencies:

• 1) Workforce readiness for initial response: We discuss the importance of having and analysing HRH data to identify both the need for and availability of HRH to support response.

• 2) Implementation while strengthening HRH: We highlight the importance of HRH governance during the pandemic for implementing measures to increase, maintain and protect health workers. We also summarize these measures.

• 3) Continually monitoring, reviewing and updating the response to keep responding to new waves of COVID-19 and the challenge of vaccination.

Workforce readiness for initial response

Data on HRH and information analysis are key elements in planning preparedness to respond to a health emergency. We identify three mechanisms for improving real-time, comprehensive and detailed information for dialogue and decision-making when preparing for health emergencies: (a) HRH information systems (HRIS); (b) methodologies to estimate HRH needs; and (c) teams to analyse information for decision-making. Table 1 shows the eight countries of the case studies classified under this schema.

Table 1 HRH information for workforce readiness in preparedness for the COVID-19 response

HRH information differed in the countries studied, both by frequency of collection and by occupational groups. Data reported in WHO’s National Health Workforce Accounts (NHWA),⁸ such as stock or density by occupation [15], show that in Chile, Colombia, Ecuador, Peru and Jamaica, information on HRH is collected regularly on an annual basis. Belize, however, has data series only on medical doctors and nursing personnel. In contrast, Bolivia and Grenada have data for specific years only on medical doctors, nursing personnel, dentists, and pharmacists [15]. Thus, challenges remain, such as standardizing indicators on HRH and improving HRIS interoperability.

Table 2 outlines the HRIS in six LAC countries, both before and after the COVID-19 pandemic, to track confirmed COVID-19 cases and deaths among HRH. The data published vary in terms of access of information and whether publicly available or not; frequency of publication (regular or non-regular basis); and disaggregation of data by occupational group, sub-national level, sex, age and source of infection. Collecting and analysing information on total HRH and COVID-19 confirmed cases and deaths therein contributed to strengthening existing HRH data and information analysis.

Table 2 HRIS available in the countries studied before and during the COVID-19 pandemic

In the five Latin American countries studied, estimations were done on HRH shortages, in order to plan their response to the COVID-19 pandemic. However, we did not find evidence of these calculations in the three Caribbean countries studied. In all five Latin American countries, an initial deficit was projected of 34 261 additional health workers, which represented between 0.54% and 4.17% of total HRH [12]. By occupational group, all five countries had a shortage of doctors and nurses. These shortages led the countries to develop regulations facilitating the hiring and deployment of additional personnel, as well as redeployment of existing personnel. Apart from Colombia, these estimates only applied to the public health sector [12]. Estimating and analysing HRH needs and demand during COVID-19 was useful for identifying total HRH availability in the countries. Doing so also provided evidence to plan the COVID-19 response, in terms of addressing HRH gaps at national and sub-national levels, planning the vaccination strategy and identifying potential financial needs related to HRH (Table 3).

Table 3 Methodologies to estimate HRH needs in Latin America and teams dedicated to analysing HRH information

These projections used methodologies already in place, with additional assumptions in the case of Chile and Colombia. Bolivia used the PAHO model. Peru and Ecuador implemented new methodologies. Teams dedicated to HRH analysis and planning within the ministries of health (MOHs) were key in carrying out analyses to aid in informed decision-making [12] (Table 3).

Through the process of planning the response, countries have identified the importance of both HRH data and information analysis in understanding HRH dynamics and issues, and as well as in identifying policy actions. Policy dialogues in the Region help countries share and discuss their experiences, including ways to improve HRIS interoperability and use evidence to support decision-making vis-à-vis HRH. In the countries studied, this has been key to initiating and/or strengthening the policy-making process addressing workforce readiness.

Implementation of the pandemic response plan by strengthening HRH

Countries faced the COVID-19 pandemic with pre-existing HRH shortages in key occupational groups, gaps in skills and competencies and/or sub-national HRH imbalances. We identified two aspects of governance⁹ crucial to preparedness and response during the pandemic: (a) aligning HRH objectives among ministries to define and produce regulation and policy actions; and (b) agreeing on the strategy for HRH management between the public and private sectors as well as central and local governments.

Caribbean countries coordinated between the ministries of health and finance to find ways to hire additional HRH [13]. The Latin American countries adopted a coordinated approach among ministries of health, education, labour, and finance to implement mechanisms aimed at increasing HRH availability, as well as their protection and training [12].

Coordination between central and local governments was needed to agree on HRH strategies at sub-national level and to share information. For example, Bolivia, Chile, Colombia and Ecuador fostered central–local relations to implement coordinated mechanisms addressing the HRH deficit [12].

Funding the additional cost of the COVID-19 response was a challenge faced by every country in the study. Aligning the objectives and coordinating subsequent measures were key factors to facilitate the implementation of policy actions and the shifting and/or allocation of financial resources. Belize, Chile, Colombia, Grenada, Jamaica and Peru mainly used existing resources from the general government budget. Ecuador supplemented them with grants and loans from multilateral organizations. In Bolivia, the main funding source was a World Bank loan that had been made available before the pandemic and was repurposed. All countries additionally received donations from other countries and international agencies like PAHO, as well as PAHO technical cooperation. The three Caribbean countries received training, logistics and financial support from PAHO [12, 13].

The eight countries used different mechanisms for coordinating actions with the private sector. In the Caribbean, the private sector was mainly involved through donations to protect and support HRH [13]. In Latin America, there were agreements between the private sector and the government to increase HRH availability (i.e. universities), to provide training and to protect HRH mental health. These involved input and assistance from academic and research entities as well as professional organizations (i.e. licensing boards). Ecuador and Bolivia obtained loans from multilateral organizations to help fund their COVID-19 response [12].

All countries adopted measures to increase or maintain HRH and to protect and support them. These we shall summarize in the next section.

Securing and increasing HRH availability

In the Caribbean countries, HRH shortages existed as a direct result of HRH migration [18, 19], especially of nurses. An additional cause was limited HRH production within the countries analysed, thus impacting the quality of care delivery [16]. In line with the WHO global code of practice on the international recruitment of health personnel (WHO, 2010), in view of the private sector actively recruiting health workers from countries facing critical health worker shortages, there is a need for enhanced technical, financial and other support to the countries of origin of migrant health workers. Indeed, in order to prevent this from happening, there must be a push to avoid and prevent this practice.

In the Latin American countries, HRH availability dropped when workers had to go into isolation, became ill or died from COVID-19. In countries like Bolivia and Ecuador, health workers refused to attend COVID-19 cases due to lack of PPE and unstable contracts [12]. Table 4 presents eight mechanisms identified across the countries studied to maintain and increase HRH availability during the COVID-19 response. Table 5 presents the strengths and challenges of said mechanisms.

Table 4 Measures to maintain and increase HRH availability

Table 5 Strengths and challenges of measures to maintain and increase HRH

Protecting and safeguarding HRH

The health emergency acts ratified in the countries allowed for adopting integrated, multidimensional measures to reduce the risk of infection among HRH, thus preventing and mitigating mental health disorders and reinforcing training. These measures were accompanied by specific economic incentives in some of the countries in both sub-regions, such as extra or regular bonuses (see Table 6) and higher remuneration levels. Some countries in South America implemented non-financial measures, such as life insurance or the recognition of COVID-19 as an occupational disease for HRH [12, 13].

Table 6 Measures to protect and safeguard HRH

Factors related to occupational safety also limited the supply of health workers [24]. These included a lack or improper use of personal protective equipment (PPE), non-compliance with infection prevention and control (IPC) protocols [25], mental health disorders [26,27,28] and insufficient training. Other employment-related factors include work contracts with inadequate and/or late payment without insurance coverage to mitigate the risk of infection or death. Addressing these factors has been a fundamental component of the pandemic response in all the countries studied. Table 6 summarizes these measures, as well as the lessons learned.

Monitoring, reviewing, and updating the response

Countries moved towards three goals in the process of monitoring, reviewing, and updating the response: (i) strengthening response through primary health care; (ii) planning the workforce needed to implement the vaccination plan; and (iii) securing long-term HRH availability.

In the face of the second wave, countries updated their COVID-19 response plan, placing greater emphasis on care for suspected, probable and confirmed cases through the primary health care system. Moreover, designing the national vaccination plans required reviewing the HRH teams needed to implement it. Chile had the necessary HRH because nursing personnel had already been involved in the national immunization plan, which had approved midwives and dentists to administer vaccines. All other countries needed to utilize mechanisms that would ensure a sufficient supply of vaccinators: in Latin America, this was done through training; and in the Caribbean, through volunteers and retired nurses.

The pandemic has demonstrated the importance of ensuring improved working conditions in the health sector. Balancing decent work with flexibility in hiring and working conditions seems to be the main challenge to the continued use of the hiring mechanisms implemented. Some countries are finding ways to absorb new HRH in a permanent manner and/or to improve contract stability [29]. For example, Ecuador enacted a law through which HRH involved in COVID-19 care under short-term contracts would be hired under a regular contract.

In some countries, HRH were showing hesitancy to COVID-19 vaccination. A study conducted by PAHO in 14 countries of the Caribbean identified that 23% of respondents displayed some level of vaccine hesitancy, chiefly nurses (34%) [30]. There were significant differences among health workers by age (with younger age groups being more hesitant), as well as by categories and specialties. Findings from the study guided interventions to promote vaccine acceptance among health workers, including communication strategies targeting specific HRH categories and age groups. These findings contributed to informed policy development through the HRH Action Task Force and the ministers of health from the CARICOM countries.

A 2022 survey among health workers in 16 countries of Latin America indicated vaccine hesitancy among approximately 3% of all health workers (PAHO, [13]. In 2021, Bolivia conducted a survey among HRH while developing their vaccination plan. It reported that 55% of the health workers surveyed expressed willingness to accept vaccination if the vaccine were available, and 57% would recommend it to a family member. These low acceptance rates for the COVID-19 vaccine put the vaccination plan at risk and provided evidence for the government to implement training sessions to mitigate vaccine hesitancy [31]. A year later, PAHO identified vaccine hesitancy among health workers in Bolivia to have dropped to 2% [13].

Lessons learned and challenges for future actions and preparedness policies

A key lesson learned in this study is that health workforce readiness is a critical element for preparedness during any health emergency, and that investing in the primary health care workforce is an investment in health security. This paper has identified the importance of HRH data and information analysis, HRH governance and the need to improve the design of effective retention mechanisms through improved working conditions.

Preparing and implementing the COVID-19 response required data and information on HRH, which helped strengthen existing HRH data for information analysis or created mechanisms to collect it. Based on the case studies, we identified three main areas for improving HRH information and its use in decision-making: (1) HRIS; (2) methodologies to estimate HRH needs; and (3) analysis teams to analyse information for informed decision-making.

Through policy dialogue, we identified various opportunities to improve HRIS. The first was the need to adopt standard definitions. The second was to integrate HRIS to combine HRH information from both the public and private sectors, along with national and regional information. For example, policy dialogue in the Caribbean through the HRH Action Task Force identified and chose WHO’s NHWA mechanism for integrating HRH data. Some 34 core HRH indicators were identified and classified into three levels of complexity. This shows how the countries made efforts to identify HRH needs. Some countries used methodologies that they adapted to their own needs, while others used the PAHO model or produced new methodologies. Defining adequate variables and assumptions was important for modelling. An outcome of the policy dialogues is that both the Caribbean and Latin America countries need to develop technology platforms to reinforce the analysis capabilities of their multidisciplinary teams.

Countries coordinated with different stakeholders to align objectives, allocate resources and agree on policy actions. In the Caribbean, ministries of health from the CARICOM countries adopted policy actions to strengthen HRH response and increase vaccine acceptance among health workers there [13]. In Latin America, some countries created a different wage scale for the sub-regions to address the uneven distribution of HRH at the sub-national level. However, this policy proved insufficient to incentivize HRH mobility [12].

The policy dialogues have spurred further evidence being collected for analysis of effective incentives to mobilize HRH. WHO developed the Working for health 2022–2030 action plan [32] to strengthen health systems for universal health coverage, while particularly focusing on essential public health functions including emergency preparedness and response. The plan provides a set of strategic actions and a platform for enabling domestic, multisectoral and international cooperation and coordination. Moreover, it proposes concerted actions across three areas: (a) planning and financing, (b) education and employment, and (c) protection and performance.

Policy dialogues that use information and lessons learned contribute to aligning policy priorities and objectives regarding the protection and care of HRH throughout the region. This process can be guided by the Global health and care worker compact to rapidly assess, review and monitor good practices.

The pandemic highlighted the importance of protecting HRH’s mental health, with actions centred on prevention. However, policy dialogues have stated a further need to measure the effects of these preventive strategies and move on to developing routine treatment mechanisms for health workers. Additionally, the World Innovation Summit for Health reaffirms the obligation to protect and safeguard HRH, by ensuring decent work and a safe, enabling work environment [21]. The lessons we have learned from the Latin American countries suggest the need to update competencies at both the individual and team level, through continuous health education plans within the framework of new technologies.

The pandemic has emphasized the need for countries to be more proactive in their approach to HRH. Challenges ahead include developing legal structures to provide permanent support for the mechanisms created and strengthening those already institutionalized, as well as absorbing the newly recruited HRH to reduce pre-pandemic gaps and improve working conditions. Increasing HRH absorption capacity depends on identifying funding sources and finding ways to accelerate hiring processes.

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