Equity in achieving Universal Health Coverage must include equitable treatment of health workers
In October, 2018, the world celebrated 40 years since the Alma Ata Conference on Primary Care. To mark this occasion, the WHO launched the Astana Declaration on Primary Health Care, meant to contribute to Universal Health Coverage (UHC) under the Sustainable Development Goals (SDGs). Subsequently, the operational framework was circulated for comment. Although the operational framework includes a section on health workforce and on appropriate payment schemes for providers, these sections are largely disconnected from the discussions of equity and participation elsewhere in the document.
Health workers—at all levels—cannot be seen as instrumental cogs in a mechanistic health system to produce certain results at a certain cost. Front-line health workers lie at the center of what makes a health system function (or not function) as a core social institution in society. This is true when an Ebola crisis emerges in a conflict-riven country; in a high-income country such as Japan, where the elderly are allowed to remain in their homes because of primary care workers– and everywhere in between.
And it may seem obvious, but in this global context bears stating explicitly: health workers have rights– as workers and as human beings. For decades now, labor rights have been continually eroded in favor of business-friendly environments, and “greater efficiency”– which often excludes the intangible costs of reduced quality and distorted incentives. Even so-called “constitutional blocs”, which incorporate international treaties into constitutional law in a number of Latin American countries, have generally been selective about which ILO treaties have constitutional status (e.g. those that directly relate to “human rights” such as health and prior consent of indigenous communities) and which others can be treated on par with ordinary legislation. Yet, at a time when democratic ideals and realities are under threat from both tyranny and egregious inequality, defending the rights of workers—including health workers—has never been more important.
Achieving UHC runs the risk of becoming an overly technocratic undertaking if we collectively forget that labor movements were responsible for achieving expanded health coverage and many other benefits of the welfare state. Similarly, the flurry of academic attention to health governance risks becoming irrelevant if the rights and perspectives of health workers are not considered. Finally, “human rights” have become a mantra in discussions around UHC; to make that matra meaningful, we should never forget that it erodes a person’s dignity to have to plead for conditions or compensation that should be theirs as a matter of right.