No health system can function without health workers — nurses, paramedical professionals, medical laboratory technicians, care assistants, and more — who make it possible to deliver health care. This has led the World Health Organization (WHO) to declare “No health without a workforce” as a universal truth. Yet relatively few studies have analyzed the relationship between health workforce and health outcomes, and some such cross-country and within-country studies show inconsistent results.
A new study published in the journal Social Indicators Research addresses this gap by investigating the strength and significance of the associations of the health workforce with multiple health outcomes and COVID-19 excess deaths across countries. The coauthors of the study — Karen Eggleston, APARC Asia Health Policy Program Director and FSI Senior Fellow, and Jinlin Liu, a professor at China’s Northwestern Polytechnical University’s School of Public Policy and Administration and a 2019-20 visiting scholar at APARC — find that higher density of the health workforce was significantly associated with better levels of multiple health outcomes and with a lower level of COVID-19 excess deaths per 100,000 people.
The study also confirms the pivotal role of socioeconomic factors in affecting health outcomes and underscores the wide disparities in health outcomes across countries in different income categories. In light of the strains on the health workforce during the coronavirus pandemic, this research also emphasizes the importance of investing in the health workforce to strengthen health system resilience and achieve long-term improvement in health outcomes.
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Eggleston and Liu investigated how the density of skilled health workers — medical doctors and nursing and midwifery personnel for each country — affected six measures of health outcomes. These measures included maternal mortality ratio, under-five mortality rate, and neonatal mortality rate — all of which are health-related Sustainable Development Goals (SDG) indicators — plus healthy life expectancy at birth, the mortality rate of teens and adults aged 15−60, and infant mortality rate. The researchers also examined COVID-19 excess deaths per 100,000 people as a health outcome measure proxying for the health impact of the coronavirus pandemic.
Additionally, Eggleston and Liu collected and analyzed data on four measures to account for country-level socioeconomic factors pertinent to determining health outcomes. These explanatory variables included health spending per capita, gross national income per capita, poverty headcount ratio, and the mean years of female schooling as a proxy for female educational attainment. They used the latest WHO dataset on the global health workforce, covering 191 WHO member countries.
The researchers found that countries with a higher density of skilled health workers could expect to have better health outcomes across all six measures of health outcomes. Unsurprisingly, high-income countries generally enjoy a high density of skilled health workers and world-leading health outcomes, whereas low-income countries suffer from a shortage of health workers and poor health outcomes. A higher density of skilled health workers was also significantly correlated with a lower level of COVID-19 excess deaths per 100,000 people, highlighting the importance of the health workforce under the pandemic.
The cross-country results confirm the importance of the health workforce in affecting multiple health outcomes. “Therefore, investment in health workforce should be an integral part of the strategies to improve health outcomes and achieve health-related SDGs for every country, especially for low- and lower-middle-income countries,” write Eggleston and Liu. The vast majority of these countries (about 80%) are tremendously off track to meet the health-related SDGs by 2030.
From a global perspective, the data underscores the wide disparities in health outcomes between different countries, especially between those most and least advantaged (e.g., healthy life expectancy at birth of 44.9 years in the Central African Republic compared with 76.2 years in Singapore).
It is difficult, however, to improve disparities in health outcomes between countries in different income categories by improving the density of the health workforce alone. The reason is that socioeconomic factors, as the data confirms, are critical determinants of health outcomes. For example, higher health expenditure per capita and the poverty headcount ratio have significant associations with all six health outcomes, while female education is interrelated with broader social determinants of health.
Thus, the relationship between the health workforce and health outcomes is the cause and effect of broader socioeconomic and health-system developments. “A strong health workforce contributes to better health outcomes and is itself a manifestation of a country’s previous investments that reduced poverty, improved health outcomes, and laid the foundation for a robust health system,” Eggleston and Liu explain.
Investment in the health workforce is an urgent task, the researchers conclude. It should be an integral part of strategies to achieve health-related SDGs, and these strategies, in turn, should include means to achieving complementary non-health SDGs related to poverty alleviation and expansion of female education.