Comments on Expert Group background note for the first meeting of the UN High-Level Commission on Health Employment and Economic Growth
From the outset it should be stated that PSI is pleased to see a briefing paper that establishes a tone of seeing healthcare employment as an investment, not merely a bracketed negative on an economic balance sheet. For a long time PSI has spoken of the need for the investment in public services as an economic stimulus. However, we have also been speaking for too long of the repeated tragic outcomes where failures to invest have occurred.
It is PSI’s position that only through public investment in public services that the challenges set by the 2030 Agenda for Sustainable Development can be met. Questions of healthcare, whether they are funding, resource allocation or accessibility questions all become political questions. We therefore challenge the question of how much the global forces are shaping favourable conditions. The global forces are a result of political decisions; the decision to bail out the banks, the decision to implement austerity measures, the decision to cut revenue sources and the decision not to close tax avoidance loopholes. These forces are not out human control.
Our response to the background note is based on our core values, these being:
Our members who work in the healthcare and social services industry are strong advocates of evidence based practice, ensuring that the systems of care, and the care itself, is actually going to deliver the outcome needed. Often evidence is dismissed on economic terms.
Unfortunately the recent Ebola and Zika Virus epidemics are totemic of the lessons we are failing to learn on a global level. These lessons talk of the need for adequate numbers of well-trained healthcare workers who are appropriately resourced. They talk of the need for regulation, and more importantly accountability and enforcement of these regulations, within healthcare systems and they speak of the need for a whole of government / societal approach in both preventative and reactive situations; the need for robust and coordinated services at the primary acute and post acute service levels.
PSI argues that universal healthcare requires public service provision and a predominately publically educated and employed workforce. We make this argument based on governance issues such as cost effectiveness, regulation, enforcement and agility in meeting societal needs. We therefore support the intent of Policy Briefs No. 14 though we have reservations about the proposed financing methods referred to. With regard to workforce planning affiliates of PSI talk of staffing levels that allow safe patient care, in example nurse to patient ratios, being supported by strong academic evidence. Despite this evidence it is rare for a government to legislate minimum staffing levels or for private employers to allow such provisions to exist in workplace collective agreements. Even in wealthy jurisdictions staffing levels are held out as an economic decision (based on cost of wages) rather than a healthcare decision. Implementation of evidenced based practice with regard to staffing levels is predominately within public sector healthcare systems where the workforce has acted through their trade unions in order to achieve safe patient care.
It must be recognised that whilst government representatives within the United Nations speak of Sustainable Development Goals and healthcare as a human right, as healthcare not fitting within an economic determinant paradigm, they are not consistent in their policy choices. These same governments are signing free trade agreements that are pushing healthcare into the private sector, that are protecting the profit driven monopolies of pharmaceutical companies, that are removing government’s own right to regulate and are bringing down national budgets that reduce access to social services. These forces are not beyond human control. We know that public healthcare systems are more effective and efficient than private healthcare systems. Evidence from countries with universal healthcare access systems, such as France and Italy were for many years considered the most effective, or the NHS, or the Australian universal insurance system (Medicare), shows that they are far more efficient than the privateer based systems such as in the US whilst costing less. It is not the absolute percentage of GDP that determines health outcomes; it is how the healthcare is provided.
In order to ensure an appropriate health workforce governments must retain the right to regulate how and where healthcare is provided and how and where training is provided. This requires long term planning in ensuring the right skills and knowledge are being developed for the needs of tomorrow. It requires governments to have regulatory control over numbers and content of education. The free market will only provide training where there is a profit to be made. Health tourism and the profit heavy acute care setting, which hold the promise of higher wages, will increasingly dictate which courses are provided and where. For this reason we support the thrust of Policy Briefs No. 1 & 3 and challenge that of Policy Brief No. 11. The ability to regulate and enforce those regulations is demonstrated as lacking even in well-resourced economies. We do however support within No. 11 that “the regulatory and institutional environments governing health employment are as important as questions of fiscal space”.
PSI recognises the complex choices facing healthcare workers when considering options to migrate. We highlight that the country of origin loses an investment in training, and much needed skills and knowledge often to the benefit of wealthy nations. However, we also recognise the economic drivers of migration; women make up the predominant number of healthcare migrants and their remittances are important for their families and communities in the country of origin. In response to this dilemma we provide pre-decision kits in many countries. The rights of workers is a key focus of these kits in an attempt to decrease the incidence of healthcare workers becoming economically trapped as a result of qualification discrepancies, cost of living and exploitative practices. We therefore support the general premise of Policy Briefs No. 12.
PSI would like to take the opportunity to pre-emptively comment on Policy Briefs No. 15 – Decent work and social dialogue in the health sector (yet to be written). Decent work has many parameters; a living wage, the right to belong to a trade union and participate in the actions of the union, the right to a safe work place, access to ongoing education and support, sufficient down time and safe length of shifts, opportunities for professional development and advancement are a few these. Importantly for healthcare workers decent work also requires that they are able to speak freely and without fear of repercussion about the healthcare system in which they work. Many healthcare workers are required to be advocates for their patients. Within the scope of primary healthcare initiatives, where the biggest advancements in healthcare are yet to be realised, this will often mean speaking out in public with the potential of being critical of their governments. If this commission is to be effective we will need to be clear in ensuring that the rights of healthcare workers to engage in social dialogue is paramount.
 See page 2, paragraph 4 of the background note
 Which includes not only healthcare services but that communities have access to the social determinants of healthcare such as clean water, sanitation, safe housing, healthy food, education and cultural / social activities.
 In example for every additional patient above four that a registered nurse is responsible for in the acute setting there is an accumulative increase in morbidity and mortality