Workforce

In order to achieve effective coverage of high-quality PHC, the PHC workforce must be available, accessible, acceptable, and high-quality. ¹³ To achieve this, the PHC workforce should be equipped with the necessary competencies to deliver comprehensive, high-quality PHC and made up of the appropriate number and skill mix of occupations to meet population health needs and ensure that all communities have equitable access to the right care at the right time. ²⁴

• Competencies are the observable abilities--including knowledge, skills, and behaviors--of individual health workers that relate to specific work activities. Competencies are durable, trainable, and measurable. ⁵⁶ All members of the PHC workforce should have competencies related to people-centeredness, communication, decision-making, collaboration, evidence-informed practice, and personal conduct to enable them to provide comprehensive PHC services which meet the majority of people’s needs. ⁵ Competencies should be evidence-based and adapted to the country-context to reflect the list of interventions at the PHC level and structure of the PHC workforce in-country. ⁴⁵⁶⁷⁸⁹ Standards for workforce education, training, and practice should be based on these defined competencies and instituted for all occupations of the PHC workforce. 
• Skill mix describes the combination of different occupations of health workers delivering PHC in terms of numbers, diversity, and competencies. ¹⁰ PHC services are best provided by coordinated, multidisciplinary teams with the wide range of knowledge, skills, and expertise needed to provide comprehensive, holistic care that is accessible and acceptable to the local community. ^4111213 The different occupations of providers that make up a country’s PHC workforce may include family medicine doctors, nurses, midwives, community health workers, physician assistants, social workers, or others depending on the local context. The optimal skill mix of the PHC workforce will depend on the needs of the population and the best way to meet those needs within the context of the health system. ^291011121314 Some occupations of health workers, such as family medicine providers and some designations of general practitioners, are specifically trained in PHC and some countries have found having an approved medical specialty dedicated to comprehensive PHC to be a valuable and effective strategy. ¹⁴¹⁵ Additionally, integrating a diverse range of occupations, including mid-range and/or community-based workers, can help to support the realization of a diverse, sustainable workforce with the skills and reach needed to meet a comprehensive set of population health needs. ³⁴ For example, given that PHC is often delivered in both communities and facilities, community-based health care workers may be integrated into the workforce plan to support proactive population outreach. ¹⁶² For more information on the characteristics of effective community health worker programs, see resources here and here. 

To effectively meet the needs of the population, the skill mix, competencies, and distribution of the PHC workforce should be defined in relation to the needs of the population, taking into consideration dimensions such as access, population health needs, acceptability, and the context of the health system, including the service delivery model and health sector goals.

In addition, the PHC workforce must be motivated and empowered to deliver high-quality care that is acceptable to the needs and expectations of the population. ³ Health systems should promote working conditions that enhance both the capacity and motivation of the health workforce to deliver quality care and continuously improve their performance, such as through appropriate remuneration and incentives, merit-based professional development opportunities, and occupational health and safety standards. ³

Countries should strive to align their workforce development strategy with an integrated, person-centered PHC delivery model that achieves “a diverse, sustainable skill mix... and harnesses the potential of community-based and mid-level health workers in interprofessional primary care teams” ³ in order to ensure that the workforce is cost-effective and responsive to community needs. Countries will need to continuously assess the ability of the PHC workforce to deliver on their defined competencies, addressing any challenges with skill mix imbalance, maldistribution, and interprofessional collaboration (see performance management section below). 

Building an efficient and effective PHC workforce in practice relies on strong in-country capacity (systems, evidence, policies, and investments) to implement, assess, and improve effective strategies and policies for PHC workforce education, recruitment and deployment, retention, and quality assurance and regulation. ³  

• Education: Appropriate education is essential for ensuring that the PHC workforce has and can demonstrate the competencies necessary for delivering high-quality PHC, including competencies related to evidence-informed practice, person-centeredness, and collaboration. ³¹⁷ Achieving this requires that the relevant competencies for each PHC occupation are identified, that education standards are established based on these competencies, and that quality assurance systems are in place to ensure that educational institutions are adequately training on these competencies, for example by accrediting training institutions and/or licensing or certifying graduates. ⁵ It is critical that these quality assurance mechanisms be integrated into the overall workforce quality assurance system as described below to ensure consistency in quality standards from education through practice. ⁵ Additionally, in-service educational programs should be deployed to ensure continuous professional development and ongoing training as needed. ¹⁸
• Recruitment and deployment: Policies and systems for recruitment and deployment should aim to ensure that the right people are placed in the right positions in order to ensure equitable access to quality care for all. ³¹⁷ Evidence shows that in many countries there is a maldistribution of health workers, with too few serving in the public sector and/or rural areas or marginalized communities. This maldistribution often results from poor translation of policies and systems for recruitment and deployment into effective posting and transfer practice. ¹⁹ Reasons for ineffective posting and transfer include the politicization of the process, individual provider preferences for postings that are associated with greater income, prestige or personal convenience, and a lack of accurate and detailed data on the health workforce. ¹⁹ There has been a recent increase in efforts to better diagnose the underlying reasons for poor recruitment and deployment in order to identify solutions to support improvement.^20212223 For example, evidence has shown that one way to address the shortage of health workers in rural or underserved areas is to recruit students and workers directly from these communities, as these individuals are more likely to desire returning to practice in their home areas and provide services that are accepted and trusted by the communities they serve. ^16212425 You can find more information about these issues in underserved communities here and policy options for improving health worker deployment here.
• Retention: Retaining a qualified workforce--whether at the country level, within the public sector, or within underserved areas--is essential to ensure that investments made in workforce education and deployment yield the expected benefits to service delivery quality and population health. Too often, though, PHC workers in general and particularly those in underserved areas often lack access to the training and resources needed to deliver up-to-date, effective care, build their skills and competencies, and advance their careers. ²⁶ Many health workers then leave underserved areas for urban areas with better working conditions, access to professional development, and sufficient resources.²⁶ National and institutional policies and regulations can support retention by promoting job security and providing pathways for professional growth and supportive supervision, improving living conditions, promoting work-life balance, providing appropriate remuneration and incentives such as loan repayment, and ensuring a positive, non-discriminatory practice environment. ^{3172122232728}
• Quality assurance and regulation: Quality assurance and regulatory systems are essential to ensure that the PHC workforce has and demonstrates the necessary competencies and is delivering high-quality care. There are three primary goals for such systems: to ensure that the practicing PHC workforce has the appropriate training and qualifications, that records of appropriately trained and qualified workforce are collected and maintained, and that appropriate measures are taken with respect to workforce members who do not meet the established standards. ⁵ Mechanisms for meeting these goals include ensuring that all practicing workforce be licensed and/or accredited, establishing systems for issuing and investigating complaints, instituting continuing professional development and periodic re-validation of credentials/registration/licensing, and creating systems for course-correcting members of the workforce who fail to meet standards--including removal if no improvements are made. ⁵²⁹ All occupations of the PHC workforce should be covered through such systems. ⁵ In addition, users can find more information about systems for monitoring and improving the performance of the health workforce, including supportive supervision, in Performance Measurement and Management while specifics around measuring and improving provider competence and motivation are addressed in Availability of Effective Primary Health Care Services.

Achieving the above will require sufficient and appropriately targeted financing for the PHC workforce. ¹³³⁰³¹ Users can learn more about workforce financing here.

To support sustainable investments, policies, and systems for health workforce development, countries need robust workforce-related data--including workforce characteristics, remuneration patterns, workforce competence, performance, absenteeism, etc.--from the public and private sectors as well as in-country capacity to analyze and use this data to inform policymaking and planning. ³² National Health Workforce Accounts (NHWA) is a system for supporting countries to produce and use quality health workforce data and evidence in order to guide evidence-based policymaking and planning. ³¹ The NHWA includes a set of indicators for monitoring education, labor market dynamics, financing, governance, policies, and regulations, and is accompanied by an implementation guide and an online platform to support data management, analysis, visualization, and reporting.

The PHC workforce is the primary implementer of primary health care; without a strong workforce it is impossible to deliver high-quality PHC services for all.¹²³³ To develop a skilled and motivated workforce, countries will need to ensure alignment of policies, goals, and resources with the PHC service delivery model, alongside concentrated efforts to align workforce education and practice to embody the core principles of high-quality PHC: first-contact accessibility, continuity, comprehensiveness, coordination, and person-centeredness.³ By reorienting health systems toward person-centered integrated care models made up of interprofessional primary health care teams with a diverse skills-mix, countries have the potential to strengthen the quality of PHC service delivery and achieve better population health outcomes for all.³

Accreditation [of a training institution or program]: Accreditation is a form of quality assurance in which a training institution or program is assessed to determine whether it meets predetermined and agreed-upon standards. If so, the institution or program is given accredited status. ³⁴

Certification [of a profession or occupation]: Certification is, “the process whereby a profession or occupation voluntarily establishes competency standards for itself.” It is particularly useful in cases where the government has not regulated the profession or occupation through licensure. ³⁴

Community Health Workers: Community health workers are a type of community-based health worker whose primary responsibility is to conduct proactive outreach in the community to meet local population health needs. ¹⁶

Competencies: “Competencies are the observable abilities of individual health workers relating to specified activities of work that integrate knowledge, skills, and behaviors. Competencies are durable, trainable and measurable.” ⁶

Density [of the skilled workforce]: Density is measured as the ratio of active health workers per population in the given national and/or subnational area. ^31 33 

Incentives: Incentives refer to, “a particular form of payment which is intended to achieve some specific change in behaviour. Incentives come in a variety of forms, and can be either monetary or non-monetary.” ³⁶

Licensure [of an individual health worker]: Licensure is a process in which a governmental authority determines the competency of an individual health worker seeking to perform certain services and grants that individual the authority to engage in specific area(s) of practice based on demonstrated education, experience, and examination. Licensure also typically means that governments have the authority to both discipline licensees who fail to comply with statutes and regulations as well as to take disciplinary action against unlicensed individuals who practice within the scope of a licensed profession or occupation. ³⁴

Posting and transfer: Posting and transfer refers to geographic deployment of health workers. It encompasses both initial health worker posting and subsequent transfers of staff between health facilities. ¹⁹³⁷

Quality assurance: Quality assurance of the health workforce refers to systems for ensuring that the practicing primary health care workforce has the appropriate training and qualifications, that lists of those appropriately trained and qualified providers are maintained, and that appropriate measures are taken with respect to providers who do not meet established standards. ⁵

Remuneration: Remuneration is traditionally seen as the total income of an individual that may take different forms, such as salary, stipend, honorarium, and/or monetary incentives. ³¹⁶ A remuneration strategy determines this particular configuration or bundling of payments that make up an individual’s total income. ³⁶ The World Health Organization recommends that all occupations of the health workforce be remunerated with a financial package in accordance with the employment status and applicable laws and regulations in the jurisdiction. ³¹⁶

Skill mix: Skill mix describes the combination of different occupations of health workers (i.e. doctors, nurses, and midwives) in a primary care practice in terms of numbers, diversity, and competencies. ¹⁰