Empowering patients and strengthening communities for real health workforce and funding targets

The setting of ambitious targets for expanding the health workforce and improving its quality, efficiency and equitable service delivery is a task long overdue. It has been nearly one decade since the minimum needed density of physicians, nurses and skilled midwives – 2.28 workers per 1000 inhabitants – was established, but without attention to other health worker cadres. Furthermore, the estimate was based on only two areas of health worker activity – skilled birth attendance and measles immunization – that represent a minuscule fraction of people’s health-care needs.¹ As a result, it grossly underestimated the health workforce needed in low- and middle-income countries to respond effectively to the pandemics of human immunodeficiency virus infection (HIV), tuberculosis and malaria; the burden of neglected tropical diseases; unmet needs in child, maternal and sexual and reproductive health; and the growing prevalence of noncommunicable diseases. In addition to being unsuitable for responding to epidemiological trends and other contextual variables, the established worker density target was minimalistic and non-dynamic, for it conveyed the impression that meeting only the most rudimentary needs of health systems would suffice to alleviate the crisis in the area of human resources for health. No aspirational goals were set for progressively expanding and strengthening a health workforce to meet a population’s broad-spectrum health needs.

Cometto & Witter² are correct in asserting that much has been learnt about the value of properly trained mid-level³ and community health workers⁴ in improving health service coverage and efficiency. Work is still being conducted to determine the best skill mixes and workforce ratios for different countries and to establish good practice models for health workforce training, task sharing and teamwork. Although simplification, combined with equity and quality, is the overall goal, the path is laborious given the headwinds of bureaucratic intransigence, chronic underfunding and persistent brain drain. To overcome these headwinds, it is crucial that health workers be paid living wages and given incentives to work in neglected areas.⁵

Despite the above, the framework described by the authors is not inclusive enough because it omits the transformation taking place in the delivery of robust, affordable and operable point-of-care diagnostics by health workers with less training.^6,7 The possibility of making a diagnosis at the periphery of health services rather than in tertiary facilities is made even more attractive by growing evidence that dispersed community-based care is often as good as concentrated facility-based care or even better.⁸ More importantly, we have learned from HIV activists and people living with HIV that patients can and must be empowered to prevent ill health and manage their own care – in short, to be partners in their own well-being – through health literacy and communal support systems. Similarly, communities and community systems must be strengthened if they are to support patients and their caretakers in their efforts to seek care and preserve health. Only by placing patients at the centre of human resource strategies and strengthening the interface between health and community systems will we attain the efficiency and quality in health care that we seek.

Empowered patients and strengthened communities will be in a position to hold health systems and their leaders accountable.⁹ They will demand of both domestic funders and foreign donors the resources needed to recruit, train and retain health workers capable of delivering good, equitable care. They will also demand dynamic targets for strengthening the health workforce, matched with enforceable targets for adequate and sustained funding.