Health care workers: catalysts for improvement, not costs to the system

The White House Covid Summit recently convened world leaders, multilateral organizations, global health experts, and the private sector to address the pandemic. We were privileged to be among the stakeholders as representatives of Seed Global Health, which partners with governments to strengthen health workforces in countries with critical shortages.

The Summit’s main call was for collective action to heal from the Covid-19 pandemic and protect against future global health threats. To this end, we heard dialogue focused on global vaccine equity; on improving global manufacturing capacity for Covid-19 vaccines, personal protective equipment, diagnostics, and treatments, including oxygen; and on financial commitments to ensure global health security and preparedness.

What we didn’t hear was much discussion about the one factor essential for the success of all of these initiatives: the world’s “health care heroes.” This omission was surprising because health care workers are the foundation of health systems. They deliver every element of pandemic response and manage associated crises.

As Covid-19 has pushed people into poverty, increased food insecurity, reduced access to health care worldwide, reversed progress in maternal and child mortality, and worsened outcomes for infectious and chronic diseases, these increased disease burdens will only expand the need for health care workers.

Despite these truths, and the global loss of more than 100,000 health workers during this pandemic, the global community has not yet demonstrated that it will collectively change course. Without meaningful changes in priorities, the health workforce will continue to be underfunded, undervalued, and underprotected. This failure is most stark in low and middle-income countries (LMICs), feeding longstanding inequities in the global health workforce.

Long before the emergence of Covid-19, health care workers in low- and middle-income countries faced profound occupational hazards. They are at least three times more likely to be diagnosed with tuberculosis and up to six times more likely to be hospitalized with drug-resistant tuberculosis than the general population in high disease-burden countries. Health workers in Guinea, Liberia, and Sierra Leone were at least 21 times more likely to contract Ebola than the populations they served during the outbreak in 2014-2015. At least 513 health workers died of Ebola during this period, leading to a reduction in the health workforce by up to 8% in affected West African countries.

The impact is enduring: post-Ebola investments for Guinea, Liberia, and Sierra Leone have fallen woefully short of the projected recovery needs; these countries now require up to a 10-fold increase in their health workforces to reach regional averages and minimum international benchmarks for health worker to population ratios.

By 2030, there will be a global shortage of more than 18 million health care workers, disproportionately in low- and middle-income countries. Inadequate staffing already worsens the physical and mental demands of providing health care in these countries, fueled by inadequate resources, immense workloads, and emotional exhaustion from the toll of watching people die preventable deaths. Though difficult to quantify, burnout rates among physicians and nurses in African countries are high — upwards of 80% in some hospitals. Burnout and work stressors, in turn, are key drivers of health care workers migration abroad, which further compounds health workforce shortages.

According to estimates by the WHO, the average investment required to scale up the health workforce to meet what’s needed over a 20-year period is about $488 million a year per country.

The funds required to close these financing gaps actually exist; it’s the international political will that’s lacking. Domestic governments, donors, philanthropy, and the private sector have the means to meet these needs together but, according to experts at the WHO and World Bank, these stakeholders often see the recurrent costs of developing and employing a strong health workforce as a long-term financial burden they are unwilling to sustain over time.

Covid-19 presents a window of opportunity to change this narrative. As health care workers are applauded for their service, the international community must recognize that the consequences — financial and otherwise — of not investing in the global health workforce are far more devastating than the upfront costs of strengthening it.

According to researchers from the WHO, the loss of one physician represents a cost of more than $500,000 in Kenya. And estimates like this don’t take into account the potential longer-term consequences of health worker burnout and trauma, which lead to decreased quality of care and migration of health workers out of the health sector or abroad.

There are also countless multiplier effects of health workforce employment. Supporting an appropriately planned, trained, and distributed workforce can reduce inefficiencies in global health spending in the long term. Investing an additional 2% of gross domestic product (GDP) into the health, social, and education sectors raises overall employment rates by as much as 6%. It might not seem like much, but with the total unemployment rates across lower- and middle-income countries surpassing 6% in 2020, this could represent tremendous growth.

Investments in the workforce are also critical to inclusive growth. Supporting safe and secure employment in this sector reduces gender disparities, with women absorbing 60% to 70% of the jobs, and builds formal work, social inclusion, and equity. The ultimate return on investment for health is estimated to be 9:1, with each extra year of life expectancy emerging from this investment raising the GDP per capita by 4%. In other words, improving population health and investing in the health sector can elevate nations.

The World Health Organization declared 2021 to be the Year of Health and Care Workers. But as the year comes to a close, this declaration will ring hollow unless global commitments to end this pandemic and protect the world from future health crises include sustained action to protect and strengthen the health care workforce worldwide.

It is not a question of identifying the needs; those are clear: prioritizing health workers for vaccines and protective equipment now while also increasing global and domestic investments required for salaries, training, infrastructure, and morale in the long term. That requires making the choice to no longer misrepresent health workers as a cost on the system but appreciate them as catalysts to better health, economic growth, national security, and wellbeing. It is a choice to recognize them as the “heroes” that they’ve always been.

Pooja Yerramilli is an internal medicine physician at Massachusetts General Hospital and Boston Health Care for the Homeless, and a policy advisor for Seed Global Health, which partners with governments to invest in health care capacity for national, economic, and human security. Vanessa Kerry is a critical care physician at Massachusetts General Hospital in Boston, an associate professor of medicine and director of the Program in Global Public Policy and Social Change at Harvard Medical School, and CEO of Seed Global Health.