From a vicious cycle to a virtuous cycle

A vicious cycle of underfunding and losing health workers due to poor or unsafe working conditions is threatening universal health coverage, but with funded country-level workforce plans, we can turn this cycle into a virtuous one

How and why is a healthy health sector workforce essential for making all other parts of the healthcare system and community work, to deliver health for all?

With rising geopolitical tensions around the world, countries have many competing interests with both political and financial implications, causing economic and financial fragmentation. Spending on health care increased by an average of 1% of gross domestic product in Organisation for Economic Co-operation and Development countries during the pandemic, and the war in Ukraine, rising energy costs and disruptions to supply chains have now increased the cost of health care in many countries and added pressure on government budgets. However, we have learned from the pandemic that investment in health care – and particularly in the healthcare workforce – must be a priority if we are to rebuild strong and resilient health systems to meet future demands and deliver universal health coverage by 2030. As Dr Tedros Adhanom Ghebreyesus, director-general of the World Health Organization, has said many times, “There is no health without health and care workers”. 

Many studies, including the International Council of Nurses and Saudi Patient Safety Center’s white paper on Nurse Staffing Levels for Patient Safety and Workforce Safety, have shown the link between healthy workers and patient safety. In addition, safety and protection are essential for retaining the health workforce that is facing a critical shortage, is expensive to replace and is difficult to produce in rapid order. In 2021, the WHO issued its Global Strategic Directions for Nursing and Midwifery 2021–2025, which argued for the need to invest in nursing jobs, education, leadership and practice. And ICN’s 2022 report, Nurses: A Voice to Lead – Invest in Nursing and Respect Rights to Secure Global Health, added two additional policy focuses: protect the rights of nurses and other healthcare workers to build a strong healthcare system, and invest in and care for the health and well-being of nurses and other healthcare workers.

At the end of the day, all roads lead to health, as evidenced by the interdependence of so many of the Sustainable Development Goals, including SDG3 on good health and well-being. Nurses are everywhere. We recognise the deep interconnectedness of all these challenges as well as the need to help lead system level transformation.

How severely has the Covid-19 pandemic, with its deaths, stress and burnout, compounded by inflation, rising debt and poverty, hurt the physical and mental health of clinicians and other health workers?

Nurses and other health workers were already suffering from overwork, poor pay, gender discrimination, and lack of protections and rights even prior to the pandemic. ICN reviewed studies from every region of the world. They confirmed rising trauma, anxiety and burnout caused by Covid-19. The WHO reported that 115,000 healthcare workers died from the virus between January 2020 and May 2021, which ICN believes is a conservative estimate.

In 2021, close to 80% of ICN’s national nursing association members responding to an ICN survey had received reports of mental health distress from nurses working on the Covid-19 response. Many nurses still are not seeking help due to stigma or inadequate available resources.

The pandemic was the accelerant for workers to declare they would no longer work in such conditions, especially after putting their own lives and those of their families at risk. Almost every health system today is crippled by the diminished or underfunded health workforce.

We are caught in a pernicious, vicious cycle, leading to a downward spiral of losing health workers from across the spectrum of professionals and essential support workers. Poor or unsafe working conditions and environments that do not value workers lead to hazardous conditions, burnout and exodus from the workforce. As ICN emphasised in our report Sustain and Retain in 2022 and Beyond, “without effective co-ordinated action to protect, support and rebuild the nursing workforce, the current global shortages of nurses will constrain many countries from achieving UHC, and continue to undermine the effectiveness of responses to the COVID-19 pandemic.” Our Recover to Rebuild: Investing in the Nursing Workforce for Health System Effectiveness report stressed that “an essential part of the recovery and rebuild response must be to shift the policy, professional and management focus from individual nurses having to ‘cope’ and ‘be resilient’ with unbearable burdens to one where employers and organisations take responsibility for creating and maintaining supportive working conditions and adequate staffing. This is the only way to enable the health system to recover and rebuild.”

We need to change this vicious cycle into a virtuous cycle, starting with funded country-level workforce plans that address all types of health professionals and personnel. When governments say they cannot afford to invest more in health, the retort must be ‘let’s find a way to align resources because we cannot afford not to invest in health’. We have witnessed the consequences of underfunding during the pandemic and in its aftermath. Now, we need to establish a future that supports nurses and other health workers to lead the changes needed to ensure health systems are responsive and resilient. We must force a re-evaluation and realignment of funding priorities that lead to greater investments in the workforce. By making decisions to spend health budgets wisely and fund the right approaches to health, we bolster both our economic and health security.

What actions are needed now to respond, to preserve and promote health for all?

This year, ICN launched its Charter for Change, which presents 10 policy actions that governments and employers must take if they are to create and sustain healthcare systems that are safe, affordable, accessible, responsive and resilient. Briefly, these actions are:

• protect and invest in the nursing profession;
• ensure safe and healthy working conditions and respect nurses’ rights;
• recruit and retain nurses by ensuring fair and decent pay and positive practice environments;
• develop, implement and finance national nursing workforce plans;
• invest in high-quality, accredited nursing education programmes;
• enable nurses to work to their full scope of nursing practice;
• recognise and value nurses’
  skills, knowledge, attributes
  and expertise;
• engage national nursing associations as professional partners;
• protect vulnerable populations, uphold and respect human rights, gender equity and social justice; and
• appoint nurse leaders to executive positions.

If implemented, these actions will address the complex challenges faced by our health systems and lead to improved patient outcomes and overall healthcare system performance.