The health and care workforce in the Pandemic Agreement: championing equity and protecting collective capacity for future pandemics
Authors: Veena Sriram, Leah Shipton, Julia Smith, Katrina Plamondon
Journal: The Lancet Global Health (2024)

COVID-19 has highlighted, unequivocally, the need for strengthened health and care workforce policies and systems globally. As Member States negotiate a new WHO Pandemic Agreement to ensure improved collaboration, coordination, and collective action for future pandemics, it is paramount to learn from the challenges experienced and vocalised by the health and care workforce during the COVID-19 pandemic.1The Independent Panel for Pandemic Preparedness & ResponseCOVID-19: make it the last pandemic.https://theindependentpanel.org/wp-content/uploads/2021/05/COVID-19-Make-it-the-Last-Pandemic_final.pdfDate: 2021Date accessed: February 24, 2024Google Scholar Article 7 of the negotiating text references the need to strengthen and support the health and care workforce. Indeed, most articles in the agreement are impossible to execute without major investments in the health and care workforce. Despite this, negotiators have yet to fully leverage the potential for advancing equity through Article 7. The actions of governments, particularly those of high-income countries (HICs), in the domain of the health and care workforce have illustrated a pervasive set of "colonial knots" that perpetuate inequitable power relations within and across jurisdictions,2Jongbloed K Hendry J Behn Smith D Gallagher Kunuhmen J Towards untying colonial knots in Canadian health systems: a net metaphor for settler-colonialism.Healthc Manage Forum. 2023; 36: 228-234Crossref PubMed Scopus (0) Google Scholar with disproportionately negative outcomes for low-income and middle-income countries (LMICs). The Pandemic Agreement presents an opportunity to unravel these knots by addressing long-standing inequities experienced by the health and care workforce. We outline three ways to strengthen and expand Article 7, with the underlying principle that an effective pandemic strategy requires a strengthened and respected health and care workforce. The first way to strengthen and expand Article 7 is to adopt an expansive operational definition of the health and care workforce. The text should include language that explicitly recognises the breadth and diversity of the health and care workforce to ensure governments invest in the full range of health professionals needed for pandemic prevention, preparedness, and response. For example, during COVID-19, shortages of biomedical engineers contributed to a lack of adequate medical oxygen systems in LMICs.3Kitutu FE Rahman AE Graham H et al.Announcing the Lancet Global Health Commission on medical oxygen security.Lancet Glob Health. 2022; 10: e1551-e1552Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar Similarly, a failure to recognise midwives as essential workers in Canada meant limited initial access to personal protective equipment, putting them, new parents, and infants at risk.4Memmott C Smith J Korzuchowski A et al.'Forgotten as first line providers': the experiences of midwives during the COVID-19 pandemic in British Columbia, Canada.Midwifery. 2022; 113103437Crossref PubMed Scopus (2) Google Scholar The negotiating text runs the risk of overlooking this range of professionals, given that it broadly defines health worker under Article 1 and includes community health workers and volunteers as part of the health and care workforce under Article 7. Listing all types of health and care workers is impossible, but adopting broad categories in Article 1 will ensure that key groups of workers, such as clinical, allied (eg, laboratory technicians, pharmacists, paramedics, and psychologists), or non-clinical health professionals whose work is essential to pandemic prevention, preparedness, and response are given urgently needed investment, protection, and attention. The second way is to account for health workforce migration. The text must engage more directly with the reality and drivers of health workforce migration, which is a primary barrier to meeting Article 7 obligations globally. The most recent proposal for Article 3 on Principles adds a statement on the differentiated responsibilities of high-income countries.5WHORevised draft of the negotiating text of the WHO Pandemic Agreement.https://healthpolicy-watch.news/wp-content/uploads/2024/03/Pandemic-Agreement-DRAFT-revised-negotiating-text-WHO-Pandemic-Agreement_for-circulation.pdfDate: March 7, 2024Date accessed: March 13, 2024Google Scholar Revised text in Article 7 further states the need to minimise the negative impacts of health worker migration. These additions are crucial given the role of HICs in exacerbating the global health workforce crisis through continued or accelerated aggressive recruitment of health workers from LMICs in an effort to address their own labour shortages, driven by underinvestment and attrition.6Adepoju P Healthcare workforce shortages exacerbated by poaching from the global South.Nat Med. 2024; 30: 311-314Crossref PubMed Scopus (0) Google Scholar, 7Walton-Roberts M Bourgeault IL Health workforce data needed to minimize inequities associated with health-worker migration.Bull World Health Organ. 2024; 102: 117-122Crossref PubMed Scopus (0) Google Scholar This practice is catastrophic for equitable and effective health service delivery in LMICs. A new Pandemic Agreement can guide domestic and foreign policy in HICs, the text could be strengthened by explicitly citing countries' obligations per adopted international instruments, such as the WHO Global Code of Practice on the International Recruitment of Health Personnel and the global health and care workers compact. These instruments provide the foundation for ethical practices in the global health labour market. HICs have blatantly ignored these instruments and activated numerous policy tools that prioritise international recruitment of health workers—including from so-called red list countries—to address domestic shortages. By explicitly referencing countries' existing obligations, the Pandemic Agreement can reinforce urgently needed, principled collective action in the global health labour market. And the third way to strengthen and expand Article 7 is to strengthen the inclusion of health workers' contributions to pandemic prevention, preparedness, and response. Governments at national and subnational levels have, for decades, implemented deeply inequitable workforce policies, particularly for the occupational groups working closest to communities, such as community health workers, nurses, and midwives.8Jones L Hameiri S COVID-19 and the failure of the neoliberal regulatory state.Rev Int Polit Econ. 2022; 29: 1027-1052Crossref Scopus (47) Google Scholar Health workers' longstanding frustrations have been shaped by the extensive damage caused by these short-term, top-down, market-driven policies, and exacerbated through increased mistrust, violence against health workers from patients and clients, and declining health sector budgets.9Brophy SA Sriram V Zong H Andres C Mawyin MP Narayanan GL Heroes on strike: trends in global health worker protests during COVID-19. Accountability Research Center, Washington, DC2022Google Scholar, 10Devi S COVID-19 exacerbates violence against health workers.Lancet. 2020; 396: 658Summary Full Text Full Text PDF PubMed Scopus (96) Google Scholar The Pandemic Agreement is an opportunity to reimagine and respect the health and care workforce—including informal and unpaid care providers—as essential partners in combating pandemics. Accordingly, the text would strengthen the possibility for equity and the protection of health workers' rights if it called for greater participation of frontline health-care workers, the majority of whom are women, in health decision making and governance. Using more concrete language around inclusive and equitable governance of the workforce would lay the foundation for improvements in health systems and for pandemic prevention, preparedness, and response. We declare no competing interests.