Spotlight Interview

With Mubashar Sheikh
Conducted September 2008
Dr Mubashar Sheikh is the recently appointed Executive Director of the Global Health Workforce Alliance (GHWA) and is a specialist in health system policy and planning. Starting his career in Pakistan, he managed the Primary Health Care Department at the Ministry of Health and led the renowned 'Lady Health Workers' initiative. In 1998, Dr Sheikh joined the Eastern Mediterranean Office of World Health Organization where he was responsible for the promotion of Primary Health Care among member States. In 2004 he became the WHO Country Representative in Iran, and also served as Resident Coordinator of the UN system as well as the Representative for FAO. Dr Sheikh is the author of numerous policy documents, training manuals and guidelines related to health systems and human development.

ICHRN: As the new Executive Director, what are your hopes for the future of the Alliance?


Mubashar Sheikh: The critical shortage of health workers needs immediate and urgent action. We simply cannot wait any longer to address this issue. We know that there are over 4 million health workers needed to bridge the gap, and some 57 countries are facing critical shortages. We also know that these shortages are universally accepted as one of the most fundamental constraints to reaching the health-related Millennium Development Goals and other global health targets. If the global community is serious about the MDGs, it must work to fill the gap now, in the next to three years. Only then do we have some hope of achieving these targets.

My message is therefore simple – we must act concretely, and we must act now. With the Alliance, we will therefore continue to work to keep the issue on the global agenda, convene members, partners and countries to work together to find solutions, advocate for their effective implementation and facilitate the sharing of knowledge and best practices on health workforce issues.

The Alliance will build on and take forward the Kampala Declaration and Agenda for Action -- the 'roadmap' for addressing the health workforce crisis, that was endorsed at the first-ever Global Forum on Human Resources for Health that took place in Kampala, Uganda in March 2008.

Moving forwards, and with the active involvement of partners, the Alliance will develop a system to monitor the implementation of the Kampala Declaration and Agenda for Global Action, especially in the 57 crisis countries. This will be presented at the GHWA biennial Forum and shared at the global level.

The key for me, and the Alliance, is seeing progress in countries. GHWA has targeted an initial eight countries to test the GHWA approach to country work. This number is going to be increased as additional lessons are learned. Presently the Secretariat is developing a framework to ensure efficient implementation and monitoring of country support.

ICHRN: As the Executive Director of the Alliance, what are your key concerns in addressing human resources in health (HRH) issues in sub-Saharan Africa? Do these issues differ in other regions and, if so, how?

Mubashar Sheikh: Sub-Saharan Africa faces the greatest challenge and, proportionately, is the most heavily affected region of the world. Around 1.5 million health workers are needed to bridge the gap in this region. While it has 25 % of the global burden of disease, it has only 3 % of the world's health workers. There are a cluster of countries in Southern Africa that are undergoing a deep crisis: few health workers, high HIV/AIDS, malaria and TB burden, poorly performing health systems, and the highest rate of migration anywhere in the world, particularly in that region's English-speaking countries.

There are several concerns in addressing the crisis in Sub-Saharan Africa:
  • Scaling up 'production' (educating and training more health workers) is still at the initial stage and this will take time: a nursing qualification usually takes three years of training, and a physician at least five. Innovative methods (distance learning, 'task shifting' or community health worker programmes) can shorten this delay effect, but there is no "quick fix" to this problem: community health workers, nurses and physicians need each other to work effectively as teams.

  • More schools and teachers are also needed to really 'scale up', although technical advances (distance learning, IT) and increased twinning between schools can and should be used to enable this surge of students.

  • Significant financial support and technical cooperation are also necessary for improving a decaying infrastructure, as well as institutional development for improving the quality of education.

  • The next step is employment, which brings challenges of its own: many countries affected by the health worker shortage already have scores of unemployed health workers: public spending on health may be capped (due to macroeconomic constraints), and private enterprise may not be an option for individual health workers. Many countries thus lack the capacity to employ the workforce they have trained.

If nothing is done, the crisis will worsen. If action is taken – as recommended by WHO, GHWA and many field experts – with strong country ownership and leadership, stakeholder consultation, national and international funding, the crisis could be at least partially solved by 2015, thereby enabling the fulfilment of the health-related Millennium Development Goals.

But let me emphasize, this is a truly global problem. All countries are affected, one way or another -- the health worker crisis is an issue for everyone. In terms of sheer numbers, the needs are greatest in South Asia, especially in rural areas. Due to its considerable share of the world's population, Asia needs some 3 million health workers to bridge the gap.

In Europe and the Americas - including North America - the 'shortage' is also a reality. As populations (and the health workers themselves) are ageing in these countries, health care demand is constantly increasing. Currently, a number of countries in Europe and North America rely heavily on the incoming migration of health workers to sustain their health workforce.

ICHRN: The Alliance launched an Agenda for Global Action at the GWHA First Global Forum on Human Resources for Health in Kampala this year. Can you briefly describe for our readers what the Plan encompasses and how it will be used by countries?

Mubashar Sheikh: GHWA convened the first-ever Global Forum on Human Resources for Health in March 2008. The Forum culminated in the endorsement of the Kampala Declaration and Agenda for Global Action--a framework to guide development of human resources for health over the next decade.

The Agenda for Global Action is built around six fundamental and interconnected strategies, based on previous actions and commitments. Its purpose is to translate political will, commitments, leadership and partnership into effective actions.

The six interconnected strategies are:
  1. Building coherent national and global leadership for health workforce solutions

  2. Ensuring capacity for an informed response based on evidence and joint learning

  3. Scaling up health worker education and training

  4. Retaining an effective, responsive and equitably distributed health workforce

  5. Managing the pressures of the international health workforce market and its impact on migration

  6. Securing additional and more productive investment in the health workforce

Country leaders and decision-makers are encouraged to use these tools to help guide the development of their national plans, particularly as they respond to the reality of health worker shortages. Within the agreed Declaration and Plan, GHWA has been mandated to develop a system to monitor the implementation and progress of the Kampala Declaration and Agenda for Global Action, the results of which will be presented at the GHWA biennial Forum and shared at the global level.

ICHRN: How does GHWA coordinate its activities with other donor agencies and with the World Health Organization in order to meet its objectives?


Mubashar Sheikh: The essence of the Alliance is partnership. The human resources for health issue is complex, cross-sectoral and requires long-term solutions. As the issue became increasingly recognized, it was clear that no one entity can address the crisis single-handedly. GHWA was therefore created in May 2006 as a common platform for joint action. GHWA is a partnership dedicated to identifying and implementing solutions to the health workforce crisis. It brings together a variety of actors, including national governments, civil society, finance institutions, workers, international agencies, academic institutions and professional associations. The Alliance is hosted and administered by the World Health Organization - one of the key partners. The GHWA Secretariat works closely with both the Human Resources for Health Department of the WHO and the wider Health Systems and Services cluster; and works with other WHO departments and clusters as well as many external agencies. GHWA's member activities are the central driving force of the Alliance. In its convenor role, GHWA works to promote synergies between partners including working closely with all global development partners and global health initiatives.

ICHRN: What has been the impact of macroeconomics on HRH policies in developing countries in recent years? How should policies change in order to strengthen health systems and support the priority HRH issues?

Mubashar Sheikh: In 2004 WHO, the World Bank and the Joint Learning Initiative (JLI) on Human Resources for Health and Development recognized that an essential part of the work of supporting countries for HRH development, at the country level, is taking into account broader development and macroeconomic policies, and strengthening health systems accordingly. This requires agreement on how to engage with governments and the different processes currently under way, such as PRSP (Poverty Reduction Strategy Papers) or MTEF (Medium Term Expenditure Framework).

In the 2004 joint work there was also an acknowledgement that HRH issues are strongly linked to non-health policies and should be dealt with in the context of development and macroeconomic policies,

GHWA is engaged in progressing some of the objectives based on this wider approach such as:
  • Supporting and facilitating the development of HRH policies and costed HRH development plans to attain MDGs and to implement development policies, through the work of the Financing Task Force.

  • Establishing mechanisms to identify common challenges and lessons learnt in various countries (Task Forces and working groups that address global challenges and try to provide solutions/ recommendations);
  • Building technical capacity in countries to support HRH analysis and solutions (to support the work of partners and members who work at the country level, such as WHO, Capacity Project).

Civil society groups argue that the problems of fiscal space and macroeconomic policies are not adequately addressed and that these depress spending in health and education sectors. GHWA and partners take these concerns very seriously and are working to see how and where issues can be addressed. The Kampala Declaration and Agenda for Global Action emphasise that, to find sustainable solutions to the crisis, governments need to increase their own financing of the health workforce, with international institutions relaxing the macro-economic constraints on their doing so. We will continue to advocate for this.

ICHRN: This year the International Council of Nurses, International Pharmaceutical Federation, World Confederation for Physical Therapy, World Dental Federation and World Medical Association and the International Hospital Federation, with support from the GHWA, will launch a positive practice environments campaign. This campaign promotes safe and healthy workplaces, thereby strengthening health systems and improving patient safety. What other key interventions will the Alliance undertake to promote safe and healthy workplaces?


Mubashar Sheikh: The Positive Practice Environments (PPE) Campaign is critical to recruitment and retention of health workers and GHWA is delighted to be supporting this important initiative. Indeed, the importance of this campaign was underlined by the Alliance at the recent International AIDS Conference, held in Mexico, where GHWA co-hosted a satellite session that, in part, focused on the issue of breaking down AIDS-related stigma within the health professions and towards health workers living with HIV. The PPE campaign, and others like it, are essential components actively taking this debate forwards, and making a real and lasting difference for the way health workers carry out their work. Health workers are the very essence--the heart--of functioning health systems and their safety and well-being is of paramount importance. This is something the Alliance promotes across its work. The Health Workforce Advocacy Initiative - the civil society group affiliated with GHWA - has also put together some exciting and highly important work on this issue, recently publishing 'The Right to health: a Guide for government officials, NGOs, health workers and development partners' which underlines the importance of incorporating human rights into health workforce planning to ensure healthy and appropriate work environments for health workers.


ICHRN: What are your success criteria for assessing the impact of GHWA?


Mubashar Sheikh: In very broad terms - success would mean resolving the health workforce crisis so that everyone, everywhere has access to a skilled, motivated and supported health worker. This is an ambitious goal, but one that is entirely necessary if we are serious about making health and development progress. We know that addressing the issue of health worker shortages can have a real and dramatic impact on countries' health indicators - such as levels of maternal and newborn survival and numbers of people receiving critical treatment for AIDS, TB and malaria. That is why we will be closely monitoring the Kampala Declaration and Agenda for Global Action - especially in the 57 crisis countries facing 'critical' shortages - to see how the world is progressing and where more work is still needed.