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. 2013 Nov 1;91(11):853–863. doi: 10.2471/BLT.13.118729

Human resources for health and universal health coverage: fostering equity and effective coverage

Ressources humaines pour la santé et la couverture sanitaire universelle: promouvoir l'équité et une couverture efficace

Los recursos humanos para la salud y la cobertura sanitaria universal: cómo fomentar una cobertura eficaz y justa

الموارد البشرية الصحية والتغطية الصحية الشاملة: تعزيز الإنصاف والتغطية الفعالة

卫生人力资源和全民医疗保障：促进公平和有效覆盖

Роль кадровых ресурсов здравоохранения в вопросе всеобщего охвата медико-санитарной помощью: обеспечение справедливого доступа и эффективного охвата

James Campbell a,✉, James Buchan b, Giorgio Cometto c, Benedict David d, Gilles Dussault e, Helga Fogstad f, Inês Fronteira e, Rafael Lozano g, Frank Nyonator h, Ariel Pablos-Méndez i, Estelle E Quain i, Ann Starrs j, Viroj Tangcharoensathien k
PMCID: PMC3853950  PMID: 24347710

Abstract

Achieving universal health coverage (UHC) involves distributing resources, especially human resources for health (HRH), to match population needs. This paper explores the policy lessons on HRH from four countries that have achieved sustained improvements in UHC: Brazil, Ghana, Mexico and Thailand. Its purpose is to inform global policy and financial commitments on HRH in support of UHC.

The paper reports on country experiences using an analytical framework that examines effective coverage in relation to the availability, accessibility, acceptability and quality (AAAQ) of HRH. The AAAQ dimensions make it possible to perform tracing analysis on HRH policy actions since 1990 in the four countries of interest in relation to national trends in workforce numbers and population mortality rates.

The findings inform key principles for evidence-based decision-making on HRH in support of UHC. First, HRH are critical to the expansion of health service coverage and the package of benefits; second, HRH strategies in each of the AAAQ dimensions collectively support achievements in effective coverage; and third, success is achieved through partnerships involving health and non-health actors.

Facing the unprecedented health and development challenges that affect all countries and transforming HRH evidence into policy and practice must be at the heart of UHC and the post-2015 development agenda. It is a political imperative requiring national commitment and leadership to maximize the impact of available financial and human resources, and improve healthy life expectancy, with the recognition that improvements in health care are enabled by a health workforce that is fit for purpose.

Introduction

In December 2012, the United Nations General Assembly called upon all governments to “urgently and significantly scale up efforts to accelerate the transition towards universal access to affordable and quality healthcare services”.1 The evolving momentum for universal health coverage (UHC), with its principles of equity and social justice, aims to ensure that all members of a society can access the health-care services they need without incurring financial hardship.2,3 UHC encompasses the three dimensions of who is covered (population coverage), what is covered (health-care benefits) and how much of the cost is covered (financial protection), all of which may expand over time.4

Addressing these three dimensions of UHC5–7 within the boundaries of fiscal space8 is challenging for all countries. It requires continuing political commitment and leadership to distribute available resources, especially human resources for health (HRH),9 in an efficient, equitable and sustainable manner to match population needs. Overcoming the inequitable distribution of services is particularly critical.10

High-, middle- and low-income countries alike are facing fundamental health challenges stemming from demographic changes, ageing populations, the growing burden of noncommunicable diseases and emerging public health threats such as drug-resistant malaria, tuberculosis and pandemics. Several countries of the Organisation for Economic Co-operation and Development (OECD), hit by the global financial crisis, are revisiting health benefits, coverage and protection – either to reaffirm commitments or cut services.11 In low- and middle-income countries, other evolving dynamics will shape efforts to achieve UHC, including epidemiological transitions,12 economic growth, increased health expenditure and diminishing international health aid – or its reprioritization.13–15 In the next decade, an increasing number of African and Asian countries will become able to finance essential health services from domestic resources and will then face critical decisions on how to invest these funds most effectively to accelerate progress towards UHC.16

The health workforce is central to a country’s response to these challenges. Reaching a greater percentage of the population, extending the benefit package and improving the quality of the care provided requires commensurate attention to the governance and management of the health-care workforce, including its stock, skill mix, distribution, productivity and quality. Matching population health needs with a supply of competent and motivated health workers that are both fit for purpose and fit to practise in the country context is therefore the foundation for accelerating the attainment of UHC.

Case studies: methods and findings

This paper explores the HRH policy lessons from four countries – Brazil, Ghana, Mexico and Thailand (Table 1) – purposefully selected for having achieved sustained improvements in accelerating progress towards UHC since 1990.7 Part of their success lies in the policy focus on the health workforce to expand population coverage and the health benefits package. The paper reviews the available literature on the impact of HRH policy to identify the key actions and lessons that support accelerated progress towards UHC, with special attention to “effective coverage” and equity. By effective coverage we mean the proportion of people who have received satisfactory health services relative to the number needing such services.19,20 We focus on maternal and neonatal health – areas in which comparative data are widely available, given that measuring effective coverage of UHC within and across countries is feasible by establishing “tracers” or a subset of activities indicative of overall service quality and quantity.21

Table 1. Selected demographic, economic and health sector indicators, by country, 2011.

Country Population (thousands) GNI per capitaa THE as a fraction of GDP (%) UHCb
Brazil 196 935 11 420 8.9 191 million (100%) in 2009
Ghana 24 821 1810 4.8 12 million (61%) in 2008
Mexico 119 361 15 390 6.2 104 million (98%) in 2011
Thailand 66 576 8360 4.1 65 million (98%) in 2007
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GDP, gross domestic product; GNI, gross national income; PPP, purchasing power parity; THE, total health expenditure; UHC, universal health coverage.

a In PPP international dollars.

b Population with health-care coverage and extent to which each country had attained UHC by the year indicated.

Sources: Population, GNI per capita, health expenditure: World health statistics (2012)17 and Joint Learning Network for Universal Health Coverage (2013).18

We use an analytical framework (Fig. 1) specifically adapted from the UHC “cube”4 – integrating Tanahashi’s health coverage model and the right to health 2,19,22 – to characterize the dimensions of effective coverage: availability, accessibility, acceptability, utilization and quality. The paper focuses on these four dimensions as they apply specifically to the health workforce: availability (e.g. stock and production); accessibility (e.g. spatial, temporal and financial dimensions); acceptability (e.g. gender and sociocultural); and quality (e.g. competencies and regulation).

Fig. 1.

Dimensions of universal health coverage (UHC) pertaining to human resources for health (HRH): effective coverage

Adapted from The world health report (2010),4 UN Economic and Social Council (2000)22 and Tanahashi (1978).19

Fig. 1

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The framework shifts the focus beyond the current monitoring of access to and contact with a health worker – i.e. skilled attendance at birth, or density of health professionals per 1000 population – and turns the AAAQ dimensions of the workforce into the key determining factors of the quality of care,23 represented in Fig. 1 as the “effective coverage gap”.

We apply the four workforce dimensions to guide a process-tracing analysis of HRH policy actions since 1990. Process tracing is an analytical tool for exploring causal mechanisms and contributory steps in the chain of events that collectively support a desired outcome.24–26 We collated historical data (Fig. 2, Fig. 3, Fig. 4 and Fig. 5) on national trends in the number of skilled birth attendants (midwives, nurses and physicians) employed in the public sector. Subject to data availability, the figures also show the rates for maternal mortality, under-five mortality and either infant or neonatal mortality. We have disaggregated the national policy and governance steps on HRH by their respective AAAQ dimensions (Table 2).27 The respective policies are captured chronologically to explore their linkages to national trends in the health workforce and maternal, neonatal and child health outcomes.

Fig. 2.

Process-tracing of human resources for health policy in relation to the number of employed health professionals and health outcomes (1990–2009): Brazil

CADHRU, Capacitação e Desenvolvimento de Recursos Humanos em Saúde; HRH, human resources for health; MMR, maternal mortality rate; NMR, neonatal mortality rate; PET-Saúde, Programa de Educação pelo Trabalho para a Saúde; PROFAE, Projeto de Profissionalização dos Trabalhadores da Area de Enfermagem; PROFAPS, Programa de Formação de Profissionais de Nível Médio para a Saúde; ProgeSUS, Programa de Qualificação e Estruturação da Gestão do Trabalho e da Educação no SUS; PROMED, Programa de Incentivo a Mudanças Curriculares nos Cursos de Medicina; PRO-SAÚDE, Programa Nacional de Reorientação da Formação Profissional em Saúde; SUS, Sistema Único de Saúde; TELESSAÛDE, telehealth; U5MR, under-five mortality rate; UNA-SUS, Universidade Aberta do SUS.

Note: Data sources available from the corresponding author upon request.

Fig. 2

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Fig. 3.

Process-tracing of human resources for health policy in relation to the number of employed health professionals and health outcomes (1990–2009): Ghana

HRH, human resources for health; MMR, maternal mortality rate; NMR, neonatal mortality rate: U5MR, under-five mortality rate.

Note: Data sources available from the corresponding author upon request.

Fig. 3

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Fig. 4.

Process-tracing of human resources for health policy in relation to the number of employed health professionals and health outcomes (1990–2009): Mexico

IMR, infant mortality rate; MMR, maternal mortality rate; U5MR, under-five mortality rate.

Note: Data sources available from the corresponding author upon request.

Fig. 4

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Fig. 5.

Process-tracing of human resources for health policy in relation to the number of employed health professionals and health outcomes (1990–2009): Thailand

CNE, continuing nursing education; IMR, infant mortality rate: MMR, maternal mortality rate; U5MR, under-five mortality rate; UHC, universal health coverage.

Note: Data sources available from the corresponding author upon request.

Fig. 5

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Table 2. Role of governments, partners and the health workforce in enhancing the availability, accessibility, acceptability and quality of human resources for health .

Availability Accessibility Acceptability Quality
– Strengthen, plan, finance, manage, monitor and report on the health workforce to equitably meet population needs in health based on strategic intelligence and evidence;
– create and/or strengthen the policy, regulatory and fiscal environments to match health workforce supply, demand, affordability and sustainability in health labour markets;
– ensure the health workforce is educated, trained and continuously supported – in sufficient numbers and across their working lifespan – to achieve and maintain competencies and deliver essential health services;
– strive towards domestic security of supply (in primary, secondary and tertiary education) for qualified entrants and nationally trained health workers, with predictable, sustainable financing and adequate remuneration;
– strengthen bilateral, multinational and regional partnerships of clear mutual benefit.		 – Identify and implement solutions that remove financial, geographical and other barriers that impede access to a health worker when care is required;
– actively steward, manage and deploy the health workforce to equitably meet population needs across urban, rural and remote areas;
– promote population access to a quality health workforce across the continuum of care with effective referral across community, primary, secondary and tertiary services;
– identify and implement health workforce solutions that provide equity-focused approaches to increase access for vulnerable groups, including selecting trainees from disadvantaged communities and implementing educational strategies and incentives to enhance and sustain deployment in rural areas;
– design and implement effective policies and strategies to train and retain health workers in an enabling and productive environment.		 – Actively steward, manage and support the domestic health workforce to increase population demand for and use of high-quality services;
– explore and implement evidence-based guidance on workforce sex balance, skill mix, competencies and sociocultural needs to increase the uptake and coverage of essential services in communities and health facilities;
– develop a workforce that is responsive to the needs of people of both sexes and all ages, ethnicities and languages, and to context-specific requirements;
– review and strengthen health workforce education pathways and oversight mechanisms to enhance health workers’ accountability to consumers;
– identify and remove any perverse financial incentives and information asymmetries that affect health workers’ treatment of consumers.		 – Prioritize patients’ interests and the clinical appropriateness of the care they receive;
– review, revise and implement education and career pathways and standards, accreditation and regulatory systems, to promote and attain a quality workforce that is fit for purpose and fit to practise in relation to population-specific needs;
– link and support professional, community and consumer organizations to accelerate and sustain a quality workforce;
– strengthen patient pathways and human resource management to identify, manage and remove patient risk and improve the efficiency, effectiveness and quality of essential health services;
– design and implement country-specific workforce management, performance and monitoring systems to monitor, acknowledge and sustain high-quality services, using appropriate incentive schemes if relevant.
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Note: Governments provide the political leadership, resolve and resources to effectively steward the education, deployment, management, financing and performance of a health workforce that equitably serves population needs, promotes the right to health and accelerates progress towards population-specific, comprehensive universal coverage.

Partners, including consumers, civil society, the private sector, professional organizations, academia, and – in those countries where it is applicable – multilateral and bilateral agencies, support and facilitate the strengthening of the health workforce through mutual respect, participation, accountability, solidarity and financial subsidy, aligned with national needs and mechanisms.

Health workers, in all cadres and sectors, should be responsive to population needs and enhance the quality of health systems and services.

Governments, partners and health workers collectively and individually support a transnational, coordinated effort to strengthen the health workforce. They do so by ensuring the effective implementation of applicable international and regional conventions and resolutions on the right to health, the social determinants of health, universal coverage and the health workforce, using evidence, innovation and technologies to do so.

Adapted from Global Health Workforce Alliance (2013).27

We recognize the limitations inherent in an ex post analysis such as this. The complexity of decision-making and the confounders influencing improved health outcomes are not discussed here. Hence, while the paper explores causal mechanisms, it is beyond its scope to express causal conclusions. Instead, we use the case studies and wider published literature to identify what appears to have worked and where and draw examples of good practice from this evidence base.

Brazil

Since the adoption of its current constitution in 1988, Brazil has worked progressively to achieve UHC by setting up the Sistema Único de Saúde (SUS) [Unified Health System], an integrated health service system based on the provision of community care and improved access for underserved populations. The SUS revealed the need to expand the health workforce, both in terms of adding staff and rationalizing roles and responsibilities, especially in relation to developing new skills and building management capacity at the municipal level – the locus of health service delivery.

The government implemented several steps to produce more staff, improve their training, enhance working conditions and strengthen management capacity. The first major effort in the 1980s was the Programa Larga Escala [Long-term Programme], designed to qualify staff who had not received formal training. In 1987, before the SUS was created, the Capacitação em Desenvolvimento de Recursos Humanos initiative was launched to build capacity in HRH training and management. This was followed in 2006 by the establishment of the Programa de Qualificação e Estruturação da Gestão do Trabalho e da Educação no SUS (ProgeSUS) [Programme of Qualification and Structuring of the Management of Work and Education in the Unified Health System], a programme for strengthening HRH and, more generally, health service management.28 Other programmes, such as the 2003 Programa de Incentivo a Mudanças Curriculares nos Cursos de Medicina (PROMED) and the 2009 Programa de Educação pelo Trabalho para a Saúde (PET-Saúde) [Programme of Incentives for Curricular Changes in Medical Schools], have sought to improve service acceptability and quality and to bridge the gaps between HRH availability and need in the area of primary care. The family health team model, based on a multidisciplinary team of health workers oriented towards primary care, entails a re-orientation of the values and practices of health professionals towards the community29 and improvements in population health and, indirectly, in labour supply.30 The successes of these HRH policies have been made possible by strong political commitment and a sustained policy focus.

Through the implementation of these policies and programmes, between 1990 and 2009 Brazil managed to increase the number of health workers – nurses by 500% and physicians by 66% – well above the 31% in population growth. Between 2002 and 2012 the number of family health teams doubled – from 15 000 to 30 000 – and in 2013 access to basic health units reached 57% of the population (i.e. 108 million people).31 Over the same period neonatal mortality decreased from 26.8 to 9.7 per 1000 live births and under-five mortality from 58 to 15.6 per 1000 live births, respectively.

Ghana

A 1992 constitutional amendment to ensure the right to health enhanced the political and financial commitment to a supply-driven expansion of the health workforce in Ghana. In 1996 new regulation, accompanied by administrative decentralization and the definition of HRH staffing norms, paved the way for Ghana’s Patient’s Rights Charter of 2002. The improved availability and accessibility of health workers since the turn of the millennium enabled the development of the High-Impact Rapid Delivery strategy (2005), aimed at expanding the package of essential interventions for maternal and child health and extending population coverage. The Human Resources for Health Strategic Plan (2007–2011), which integrated the accessibility, acceptability and quality dimensions, was instituted to improve deployment and retention strategies, accreditation, regulation and licensing and continuous professional development for staff.

In 1990–2009, Ghana witnessed a rapid increase in its supply of professional health workers: 185% more midwives, 260% more nurses and 1300% more physicians. Approximately 14 000 additional professional health workers were trained and employed, a number representing four times the increase in population growth (240% versus 59%) over the same period. In the case of physicians, the growth in each 5-year period is fairly uniform, but in the case of midwives and nurses such growth dropped sharply towards the end of the period (2005–2009). The reduction has since been corrected, however, with the addition of more workers in 2010–12.

Achieving equity in access to and use of essential services continues to be challenging.32 A large share of national health expenditure – approximately 85% – is committed to health workforce salaries and incentives, but the steps taken in 1990–2009 have reduced workforce attrition, increased the capacity of health training institutions – Ghana is now one of the largest producers of physicians in sub-Saharan Africa – and improved the number and distribution of health workers.

Mexico

Policies and programmes have generated large increases in the health workforce,33 beginning with the 1995 Health Sector Reform (1995–2000), which established agreements with educational institutions for the training of human resources and increased the number of health workers nationwide.34 The coverage expansion programme (PAC) initiated in 1996 to address accessibility employed thousands of workers to support health activities in underserved areas. Staff remuneration was initially covered by loans from the Inter-American Development Bank, but the health ministry committed to paying wages in subsequent phases of the programme. In 2002 the PAC was integrated into the new Programa de Calidad, Equidad y Desarrollo en Salud (PROCEDES) [Programme for Quality, Equity and Development in Health].35,36 The Sistema de Protección Social en Salud (SPSS) [System for Social Protection in Health] and the Seguro Popular de Salud (SPS) [Popular Health Insurance] were created in 2003 to pursue the goal of UHC, with encouraging results across all AAAQ domains.37

The number of nurses and physicians increased over 1990–2009. More than 250 000 additional professionals were trained and the 80% increase in nurses and the 170% increase in physicians outstripped the population growth of 30%. In the same period, infant mortality and under-five mortality more than halved: from 32.6 to 14.6 per 1000 live births and from 41 to 17.8 per 1000 live births, respectively.38–41 Maternal mortality fluctuated over the period but was reduced by more than 50% overall, according to data from 2011.42

Attrition between education and employment is an important workforce problem that remains to be addressed. According to an analysis of the 2008 Encuesta Nacional de Ocupación y Empleo (ENOE) [National Survey of Occupation and Employment], 87% of physicians are employed, but of those who are, approximately 10% work outside the health sector. Thus, nearly one in every five physicians is not participating in the health labour market, a rate that requires further scrutiny in light of the growing private sector for medical education. In 1990, only 7% of medical students were in private schools, but by 2010 the proportion had risen to 20%. Of the 27 new medical schools established during this period, five are publicly funded and the other 22 are funded by private investments.43–45

Thailand

Although the HRH policy and governance milestones of 1990–2009 were clearly influential in Thailand’s success, critical decisions were also made in the 1970s. Such decisions continue to exert an influence 40 years later.46,47 Policies on the provision and financing of health services are pro-poor.48 Primary health care at the district level was made possible through a comprehensive health workforce policy developed in 1995 that centred on retention and professional satisfaction to encourage rural deployment,49 as well as through policy revisions introduced in 1997 and 2005. Several policies adopted from 1994 to 2009, emphasizing continuous reflection and improvement, have aimed to improve quality: development and strengthening of professional councils, regulation over curriculum standards and quality of training institutes, worker licensing and re-licensing. The establishment of the Healthcare Accreditation Institute in 2009 has consolidated these quality efforts. Post-service training in advanced practice for nursing cadres, such as nurse practitioners, intensive care unit nurses and anaesthesiology nurses, plays a significant task shifting role. Policy has centred on strengthening local and district health systems as a strategy to translate policy into practice and improve equity.

The attention to equity is particularly important. Although in 1991–2009 the overall increase in nurses (210%) and physicians (186%) outstripped population growth (13%), the accessibility dimension improved even more. For example, the ratio of nurses to people increased from 1:7.2 to 1:3.4 in 1991–2009. Regional variations in workforce deployment between the least affluent north-eastern region and affluent areas such as Bangkok have also been substantially reduced.

Case study overview

All governments have an obligation to support the highest attainable standard of health for their citizens, and many are expressing this through a commitment to the progressive realization of UHC. Our analysis provides several messages that can inform evidence-based decision-making on HRH in support of UHC.

First, success in awarding adequate priority to HRH depends on political leadership and commitment that is multisectoral, legislated and regulated through governance instruments and that remains coherent and consistent over electoral cycles. Second, strategies and actions in each of the AAAQ dimensions of HRH have brought about improvements in quality of care and effective coverage and these have resulted in better health outcomes. The focus on HRH goes beyond merely expanding the supply of workers. Each country aims for a workforce that is fit for purpose and fit to practise – made possible by whole-of-government approaches prioritizing equitable, efficient and effective health services. Third, the successes seen in the four countries examined in this paper reflect achievements made possible through partnerships in and outside the health sector: public and private entities; education, labour and finance; government and development partners; federal, state and district governments; health workers and consumers; providers, professional associations and health workers.

Discussion

In the past 10 years there has been increasing recognition that HRH are central to improving health.50,51 However, in the initial years of the “decade of action on HRH”, the policy discourse tended to focus on two issues: the “crisis” in the availability of health workers in low- and middle-income countries and the international migration of health workers. While these were critical issues then and remain so today, there is now a growing recognition of the multifaceted nature of HRH-related challenges and of the need for HRH governance and management within dynamic, local health systems.52

Since 2006, several United Nations agencies, the Global Health Workforce Alliance, regional HRH networks, development agencies, academic institutions, civil society groups and HRH observatories53 have greatly expanded the HRH evidence base and analysis, planning and management tools and have led to policy recommendations.52,53 This strategic workforce intelligence now needs to inform contemporary commitments, policy and actions beyond 2015. The key messages can be synthesized as follows:

First, training more staff is necessary in many countries, given that more than 100 countries lack enough professional health workers if the ILO’s access deficit indicator5 is used to set the threshold for density per 1000 population. However, increasing the numbers is not in itself sufficient to provide culturally appropriate, acceptable care to communities and to address the effective coverage gap. Expanding the supply, participation and availability of health workers also involves making informed decisions about the selection of trainees, the location, content and mode of training, and the development of appropriate skills for individual staff and effective skill mix across multidisciplinary teams. “More staff” only becomes “better staff” when there is sufficient and targeted funding to secure the correct investment in competencies and skills’ development over the longer term.54,55

Second, employing more staff is often necessary but not sufficient to improve access for underserved communities. Ensuring availability also requires planning to improve the accessibility, acceptability and quality dimensions – ensuring appropriate geographic and sector distribution combined with the right bundle of financial and non-financial incentives to direct and retain staff where they are most required and to motivate them to be responsive and productive.56 ”More staff” only becomes “better care” when effective local management and an enabling, “positive practice” environment57 are supported by context specific, evidence-based, responsive and fully funded HRH policies that are informed by labour market analysis and relate to defined community needs.

Third, only by addressing deep-seated health system bottlenecks – health workforce constraints being prominent among them – will countries be able to achieve their health objectives.58 Doing so will require sustained investments, including consideration of recurrent cost budgets for staffing, education, and incentives, and a policy focus over a longer period. There is a risk, however, that systemic HRH challenges will take second place to “quick wins” or “vertical” programmes (e.g. immunization or single-disease control initiatives). This is a governance issue for global health; it requires international solidarity to recognize and act on the available evidence.59 There are no effective shortcuts for decision-makers: without adequate policies and funding to achieve a skilled and motivated workforce, other investments in the health system will not yield the expected returns or may even be wasted. Investment in other key elements of the health system will also be necessary, as even the most motivated and skilled health worker needs essential supplies, equipment, infrastructure and financing mechanisms to provide quality care.

Conclusion

The key messages from the process-tracing analysis are consistent with the wider evidence.60–63 There is therefore a body of knowledge that can guide HRH policy, actions and commitments in relation to UHC. But evidence is not always transformed into policy and practice. A short-term horizon or wavering policy attention at the national or international level can hinder progress. Sustained improvements in HRH that enable the delivery of acceptable, quality care require consistent policies and long-term predictable funding, fully aligned with national needs, strategies and accountability mechanisms.

This debate should not be confined to HRH; it lays out the logic of how to maximize the accountability, transparency and impact of financial and human resources to keep global promises, measure results and improve health. It is a political imperative to face the unprecedented health and development challenges that transcend all country income groups and to shape discussion on the post-2015 development agenda for health and on the central role of HRH. Political commitment by national and global leaders is needed to build a global health workforce that is responsive to the challenges of the 21st century: one that is fit for purpose and fit to practise. While some argue that health care is labour intensive, it is worth remembering that UHC and improvements in health care are workforce enabled.

Acknowledgements

The co-authors extend their thanks and appreciation to Maria Guerra-Arias, Research Associate, ICS Integrare, for her valuable support.

Competing interests:

None declared.

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