key: cord-0726849-vjmn2v7v authors: Zapata, Tomas; Buchan, James; Azzopardi‐Muscat, Natasha title: The health workforce: Central to an effective response to the COVID‐19 pandemic in the European Region date: 2021-03-24 journal: Int J Health Plann Manage DOI: 10.1002/hpm.3150 sha: 658d265497a431e79a14316516fe7dc103e58c43 doc_id: 726849 cord_uid: vjmn2v7v COVID‐19 has reinforced the centrality of health workers at the core of a well performing and resilient health system. It has concomitantly exposed the risks of staffing and skills shortages and the importance of protecting the health workforce. The present commentary focuses on highlighting some of the lessons learnt, challenges and future needs of the health workforce in Europe in the context of COVID‐19. During the pandemic innovative and flexible approaches were implemented to meet increasing demand for health workers and new skills and responsibilities were adopted over a short period of time. We have seen the rapid adaptation and use of new technologies to deliver care. The pandemic has underlined the importance of valuing, protecting and caring for our health workforce and the need to invest appropriately and adequately in the health workforce to have sufficient, capable and well‐motivated health workers. Some of the main challenges that lie ahead of us include the imperative for better investment, to need to improve recruitment and retraining whilst better retaining health workers, a focus on domestic sustainability, redeploying and developing new skills and competences among health workers, enabling more effective multi‐professional collaboration and team work, improving the quality of education and training, increasing the public health focus and promoting ethical and sustainable international recruitment of health workers. The WHO European Region through its European Programme of Work 2020–2025 is fully committed to support countries in their efforts to continue to respond to COVID‐19 and whilst addressing upcoming health workforce challenges. health focus and promoting ethical and sustainable international recruitment of health workers. The WHO European Region through its European Programme of Work 2020-2025 is fully committed to support countries in their efforts to continue to respond to COVID-19 and whilst addressing upcoming health workforce challenges. COVID-19, Europe, health workforce, health workers, human resources for health The COVID-19 pandemic represents an unprecedented challenge to health systems, the economy and society across the world. In Europe, the pandemic has stretched and distorted all health systems and some of them have reached their breaking point during the peaks of the first and the second wave, 1 as they cope with COVID-19 but also have to maintain, as much as possible, other essential health services. The cumulative excess mortality in 2020 and 2021 (until week 5) in Europe reached 438,659 deaths. 2 COVID has both emphasised the centrality of health workers in maintaining a well performing and resilient health system, and exposed the risks of any staffing and skills shortages. Health workers have played a critical role in testing, contact tracing, diagnosing, treating and accompanying COVID patients, while also trying to provide other essential health services. 3, 4 They are now stepping forward once more, as the catalyst that will enable the roll out of vaccine programmes. In some situations, especially during the beginning of the outbreak, health workers have worked without adequate protection against the virus, putting their lives and the lives of those they live with at risk. 5 The increased workload, the increased mortality rates as a result of COVID, and the lack of protection have contributed to increased mental stress, staff absenteeism and burnout, and the appearance of psychological conditions. 6 In the European region, the pandemic has taught us some hard and important lessons regarding the health workforce. Many countries have taken innovative and flexible responses to meet increasing demands of health workers during COVID, notably during the so-called 'surge' of demand. Several countries have been successful in increasing the health workforce surge capacity by repurposing and redeploying the existing health workforce and by mobilizing and recruiting additional health workers, students and volunteers. 7 This has not been achieved without increased workload and personal stress for many. Workers have also taken on new skills and responsibilities, and many have rapidly adapted to innovative use of technologies to deliver care, sometimes remotely. The pandemic has also taught us the importance of valuing, protecting and caring for our health workforces. 8 'Valuing' our health workers and the critical contribution they have made and will continue to make means that they should be adequately paid and recognized, and be motivated by attractive working conditions. However, structural challenges remain, related to long term issues of staff and skills shortages, and sectoral and geographic maldistribution. These have been accentuated by the pandemic, but the negative impact of COVID-19 has also created an opportunity and an urgent need to address them, taking into account the harsh lessons learnt during the pandemic. 9, 10 It is well known that population health needs are changing in the European region as a consequence of ageing population (European population aged >65 has increased from 12% to 19.2% over the past 60 years), 11 the increase of non-communicable diseases and public health threats. Effective response to these growing and changing demands requires reorganization of the way health services are provided, putting the person at the centre, and 'building back better' with the foundation of a well-established primary care system. This in turn can only happen with investment in, and realignment of, the health workforce. This includes defining new more effective skill mixes, developing new competencies, encouraging and enabling more effective multi-professional collaboration and teamwork, improving the quality and responsiveness of the training and education of the workforce, increasing the public health focus, whilst increasing the availability and distribution of health workers to improve access to effective care. COVID-19 has further accelerated new ways of working and the effective use of technology. Investment in appropriate digital health can support overworked health workers and can also provide safer and more flexible ways of working, including for women who form the majority of the health workforce. 12 The impact of the COVID-19 pandemic is likely to lead to increased short-and long-term absenteeism and early retirement related to staff burnout, hence the need to both support staff health and well-being, and to consider how best to respond to the replacement challenge and need to increase supply of 'new' health workers. Investing in domestic labour markets to encourage more new applicants to health sector training, including mature 'second career' staff currently in other sectors of the economy that have been badly hit by COVID related financial impacts will be necessary. In some countries, an increase of the production capacity of health workers will also be required to meet the increasing demand of health workers. 13 COVID-19 has heavily impacted the mental health of health workers. Many of them are suffering from anxiety, depression and psychological stress. Efforts have been made by countries to provide mental health and psychosocial support for health workers, however, it will have to be intensified as the duration and severity of the COVID-19 pandemic is expanding. 6 One of the factors to be addressed in the future is the increasing high dependency on foreign health workers in some countries in the European region. On average 27% of the doctors and 16% of the nurses in OECD countries are foreign born health workers. 14 This high level of reliance brings with it risks of sustainability, and of reducing staff availability in lower income so called 'source' countries. The impact of COVID-19 on existing health workforces in some high income European countries most likely will increase their use of active international recruitment of health workers. This could have a knock-on damaging effect in other parts of the region and in other regions. There is a need for destination countries to look at sustainability by better investing in domestic health workforce and where international recruitment continues to be used, it must be underpinned by an ethical approach, framed by the WHO Code of practice for international recruitment of health personnel. 15 The spirit of the Code should guide source and destination countries of health workers migration to engage in conversations and bilateral agreements to guarantee a triple win: 15 the rights of health workers are respected, the national health systems of the sources countries are protected and the destination countries benefit from increasing health workers. Innovative approaches are emerging to promote the triple win. Countries can use bilateral agreements to specific numbers to be recruited, for how long, and to ensure that recruited workers are given full support to integrate in the destination country, and are fairly treated. This may also include specified support for workers to return to their home countries after additional training, thus enriching the health-care systems of the origin countries. 16 A second approach is enhancing the role of the health workforce diaspora in playing a vital role in the development of their homeland's health workforce capacity. Digital health could be used to facilitate the ZAPATA ET AL. -11 engagement of the diaspora in their homeland's health systems. Relatively under-resourced countries in Europe and beyond which have diaspora working in higher income country health systems could potentially benefit from this approach. 17, 18 High level policy dialogues with relevant stakeholders of source and destination countries and representatives of health workers can help to identify and action balanced solutions that benefit the three parts. WHO European Region is currently engaged in organizing one such policy dialogues between countries of European, Eastern Mediterranean and South-East Asia Regions. WHO EURO is committed to address the current and future health workforce challenges described above (achieve better investment, focus on domestic sustainability, improve recruitment and retraining whilst better retaining health workers, redeploy and develop new skills among health workers and promote an ethical international recruitment of health workers). The new WHO European Programme of Work (EPW) sets out a vision of how the WHO Regional Office for Europe can better support countries in meeting citizens' expectations about health. 19 The EPW has identified 4 flagship initiatives that include: mental health, digital health, The European Immunization Agenda 2030 and healthier behaviours. The EPW clearly states the importance of supporting Member State efforts to face post-COVID-19 recovery health workforce challenges 19 and the importance of the health workforce across the four EPW flagships. WHO has designated 2021 as the International year of the health and care workers. 20 This recognises and endorses the critical work that health and care workers are doing across the globe to effectively respond to COVID-19, but as the theme of the campaign highlights ('invest-protect-together') there is a need to continue to invest and protect the workforce. COVID-19 has both emphasised the centrality of health workers in maintaining a well performing and resilient health system, exposed the risks of any staffing and skills shortages and the importance of protecting the health workforce. Health workforce lessons learnt have emerged during the COVID-19 pandemic, namely the innovative and flexible approaches to meet increasing demands of health workers; the uptake of new skills and responsibilities in a short period of time; the rapid adaptation and use of new technologies to deliver care; the importance of valuing, protecting and caring for our health workforces; and the need of adequately invest in the health workforce to have sufficient, capable and well-motivated health workers. However, some challenges for the future remain. Greater investment in the health workforce, improving the recruitment, retraining and retention of health workers, improve domestic sustainability, redeploy and develop new skills and competencies enabling more effective multi-professional collaboration and team work, improving the quality of education and training, increasing the public health focus and promote an ethical international recruitment of health workers. The WHO European Region through its European Programme of Work 2020-2025 is fully committed to keep supporting Member State efforts to respond to COVID-19 and to face post-COVID-19 recovery health workforce challenges. 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Philippines: International Labour Organization Medical diaspora: an underused entity in low-and middle-income countries' health system development Moving health professionals as an alternative to moving patients: the contribution of overseas visiting medical specialists to the health system in Malta European Programme of Work 2020-2025: United Action for Better Health The health workforce: Central to an effective response to the COVID-19 pandemic in the European Region No conflict of interest 12 -ZAPATA ET AL. Data sharing not applicable to this article as no datasets were generated or analysed during the current study https://orcid.org/0000-0002-7807-3520James Buchan https://orcid.org/0000-0003-3002-1075Natasha Azzopardi-Muscat https://orcid.org/0000-0002-9771-2770