Better access to NCD medicines and treatments isn’t enough to ensure effective prevention and treatment of the conditions, responsible for 74% of premature deaths in the world. More attention needs to be focused on  training, retention and effective use of health care workers, said a panel of experts at the World Health Summit.

BERLIN – Following the recent UN declarations restating ambitious health goals for universal health coverage, ending TB and preventing pandemics, global health leaders are re-examining the tool box of strategies that can help push this ambitious triple agenda forward.  

Ensuring a global health workforce fit for purpose is one important thread running through all of these challenges – and far more focus needs to be placed on this in order to ensure attainment of critical health goals, particularly UHC.  

“The health workforce is the ‘lifeblood’ of a health system,” noted Katie Dain, head of the NCD Alliance. “We can be talking about access to medicines, digital technologies, but you need the health workforce in order to be delivering.” 

She was speaking last week at a World Health Summit event on Harnessing innovation to empower the health workforce for NCDs

“Some 4.5 billion people are not fully covered in terms of basic, essential health services.  And these services must now include diagnosis and treatment of chronic conditions – rather than infectious diseases alone,” Dain added.  

And the global workforce will need to double by the year 2030 in order to be able to meet the needs of a still-growing, but also aging global population – particularly for NCD care.  

 “Among the challenges picked up through UN General Assembly declarations were the sheer numbers in terms of the shortage of health workers,” Dain said, noting that “we’re going to need  80 million by 2030. And while this is a global challenge, it is particularly acute in the poorest nations.”

The problem is not just sheer numbers but more subtle workforce challenges, related to recruitment, training and retention. 

“We have to ensure that we are incentivizing them to stay within the, and we also have to be aware of the gender dimension – essentially 70% of the health workforce are women. So this is a gender equality agenda as much as it is a health agenda,” Dain said. 

Training and equipping health workers for new NCD challenges 

Along with the broad challenge of insufficient numbers, health ministries and global health leaders have to ensure that workers are better trained to deal with NCDs – particularly in low–income countries, where chronic disease prevention, treatment and care were not typically part of the basket of primary health care services – which was traditionally geared to maternal and child care, immunizations, and infectious disease prevention and treatment. 

“Seven out of ten deaths from NCDs is tremendous,” said Bente Mikkelsen, head of WHO’s Department of Non Communicable Diseases, who spoke at the panel along with Dr Osahon Enabulele, president of the World Medical Association (WMA) and Paula Head, lead of Roche’s  Policy, Value and Access team.   

Mikkelson noted that the COVID pandemic provided a sort of wake up call to countries worldwide about the importance of NCD care. “When we looked into the excess mortality during COVID, we have very strong reasons to believe that a major part of that was also because of NCDs. And unfortunately, these numbers are growing…. So there is an urgency and I think we have a golden opportunity to make a crisis into huge awareness building.”

Added Dain: “All countries, but particularly low and middle income countries, are seeing the biggest NCD burden, in terms of cardiovascular disease, cancer, diabetes, chronic respiratory, mental health, you name it. And when you ask the question, are our health workforce globally equipped, ready oriented towards dealing with chronic conditions? The very clear answer is no. 

“We all know in NCDs that we’ve been playing catch up in a way connected to some of the other big global health priorities like HIV AIDS, TB, malaria, women and children’s health. NCDs over the last decade have really gained a lot of traction, but it’s still playing catch up.” 

Globally, only 2% of development assistance for health is directed to NCDs, and “that’s still really pitiful,” she noted. 

“And we know that the health workforce is in a way, a mirror of the broader health system. And essentially health systems in many low income countries are still oriented to acute care. They’re not really oriented towards a chronic care model, which also includes health promotion and prevention, and early diagnosis – which is so important in NCDs and also really doable.”

Using technology to empower health workers 

Mikkelsen laid out a number of ways in which simple, but more effective uses of health technologies could improve the effectiveness and efficiencies of the health workforce. 

“It’s not only about new devices, new technologies but it’s really about co-creation and how we work together.  I  think many of the real solutions, will be in the co-creation of new service delivery models rather than gadgets and new examples. 

“We think it’s about the numbers of doctors, the numbers of nurses, and then we forget we have pharmacists, we have a lot of other workers that can help the health system to deliver.  So that’s also an innovation that needs to be addressed, and this leads to task shifting and how do we really integrate?”

She cited as examples, the training of HIV healthcare workers to screen for cervical and breast cancers for example. 

“For the first time, we have 21 approved proposals to the Global Fund to address HIV and the spike of cancers together.  What this means is that those who are in this space, mostly HIV -trained healthcare personnel, will get the training to be able to address the needs of, say, cervical cancer. So it’s not only about more health care workers, but it’s also about the integration of needs that can address that.”

Similarly, health workers trained in administering routine childhood vaccinations “should of course, be able to do the vaccination for HPV.  And those who offer diagnostics, should also take the time to measure the blood pressure, and the blood pressure causes. 

COVID triggered new innovation – let’s make that the norm

During COVID, health care workers and systems found new ways to innovate, so as to treat COVID patients while delivering more routine care, she pointed out. “Now, we need not to go back to normal, but to create a new normal.  Use the innovation that happened in the crisis in more normal times, to find new ways to deliver health and health care services.

More self-care education, including use of rapid at-home diagnostics is another example of innovation that blossomed during COVID – and now needs to be mainstreamed, Mikkelsen noted. 

“We’ve set a goal of having 70 of women screen with formal testing and women identified to get treatment. So what do we do? 

“I think one recommendation that was issued earlier this year that can help is the recommendation of self care interventions. Self testing, something you can do at home. 

It requires, of course, a pack of innovative digital solutions. And this can be developed together with the women that are at risk for cervical cancer, And that is also coming together with the other thing we do, which is to try to launch the AI for diagnostic assessments in the same area – as well as target product profiles to explain what are the products that we are looking for.” 

Finally, she stressed that training health workers to give more attention to preventing NCDs can help to reduce the burden of chronic disease. 

“Because that is really the untapped opportunity. We still are not on par when it comes to tobacco use and alcohol. And we are still going in the wrong direction when it comes to the obesity and physical activity,” she said, noting the average amount of medical school training on NCDs prevention currently amounts to about 3 hours in six years of training.  

Attracting and retaining health workers 

COVID also saw significant attrition of health workers, both due to deaths from the disease as dropouts due to burnout, mental health issues and even experiences of violence, noted Dr Osahon Enabulele, new president of the World Medical Association.

“So the question is how do we create enabling working conditions? How do we create conditions that will make workers stay in their various practice centers?”

Health worker retention is a particularly big problem in Africa, which has 25% of the global disease burden, but just 3% of the health workforce, pointed out Enabulele, a Nigerian medical doctor by training. 

“We have a lot of pulling away of health care workers from Africa and Asia to Europe, America and other places that do not have enough health care workers. So it looks that the production of health care workers in Africa and Asia is for export to places like Europe, and that has implications for equity, for universal health coverage”. 

“SO we are looking at how we can, you know, better, you know, address these realities, but also how can we get governments to be more accountable to their promises?” to invest in UHC. 

National policy makers need to see health workforce as an investment – which will benefit economies and societies.  

“For us,  it is how to get that real political leadership. Not seeing health care investments as a cost, but as a fundamental intervention? 

“It’s very, very important for me, the question of advocacy, how do we advocate  to governments, to the leaders to see health as a necessary investment that must be made? 

“How do we get them to replace the negative working conditions for their practitioners? How do we get them to have very progressive mechanisms to retain them? And a lot of this has to be done even in the middle-income countries.” 

Role of industry 

As head of a UK hospital during the pandemic, Paula Head saw plenty of exhausted health workers, mostly female, coming on duty while still exhausted from their last shift at the hospital.  

“But what I also saw during COVID was the most phenomenal ability to introduce innovation rapidly, effectively and safely, with the industry and the health services working closer together because we had a single focus – which was keeping the staff and their patients safe and well,” recounts Paula Head, formerly the head of a UK hospital during the pandemic, and now the Roche lead for Policy, Value and Access. 

“And so I wanted to continue that innovation journey but to do it from the private sector where I thought we could continue to make a difference. 

She sees self-testing as an example of one key area where industry can support innovation that eases the load for health workers and uses their skills more effectively to diagnose and treat a range of disease conditions. 

“We’re all familiar with self testing from COVID for doing and, of course, what that gives us is, first of all, the ability for patients to understand and manage their own health conditions. It also saves time from the phonetical physician having to take the test, send it to the lab, having to analyze the test, and so this really supports change in in the innovation and supports  the workforce. 

“Another example, done really effectively in Egypt, is end-to-end innovation in labs so that you can get a complete analysis from beginning to end, freeing up the lab workforce. 

“And then also another example I’d give is subcutaneous injection for cancer treatments.Most patients have to go through an infusion which takes many hours. The subcutaneous injection is injection under the skin; it takes much less time, which means that first of all, the patients aren’t having to stay in the hospital for long periods of time. It releases capacity, so enables those chairs to be available for people who absolutely do need an infusion. And it means that the products can be delivered in more remote areas because you don’t have to come to a specialist center for the treatment. 

“So those three are really good examples of how we’re moving technology and using innovation to support the health workforce.”

Using AI to improve health workforce performance 

But these are innovations using the technology that are available now, she pointed out.

What’s need now is more collaboration between industry and health systems to anticipate and develop new solutions, she said. 

“Say we are looking at diagnosis. If we added in AI, and Roche is working on some of this now, we can move from diagnosis to prognosis and then from prognosis to stratification and targeting patients so that we use resources we’ve got for the patients where it can make the biggest difference. 

Still, she cautions that innovation best comes from the bottom up, rather than the other way  around. 

“We’ve got to work with governments to anticipate and understand what’s coming up and then find the right solution – rather than finding the solution that we think is right,” she asserted.

Added Mikkelsen, what’s also most needed is a refocusing of health care systems on the “multi-disciplinary teams” particularly in budget-strapped low-income countries. 

“Many of these countries has something similar to a primary health care service,” said Mikkelsen. “But it’s geared to HIV, TB and malaria because that is where the funding came from. And now we really need to see the whole person.”

Image Credits: Medtronics, E. Fletcher/HPW, E. Fletcher/ HPW, WHO / Blink Media, Neil Nuia, E. Fletcher/HPW , https://www.flickr.com/photos/mikemacmarketing/42271822770/.