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ICN Policy Brief

World Health Organization Global Strategy on Human Resources for Health in

the era of the post 2015 Sustainable Development Goals:

Nursing’s Essential Contribution

Author Prof Jill White, AM RN RM MEd PhD

Purpose

The purpose of the paper is to provide a background for NNAs to have a common understanding of the current global health agenda and the process for decision making at what is a most critical time for future direction setting. ICN’s ultimate intention is to assist NNAs to better contribute to the national and global agenda setting.

This paper should be read in relation to the zero draft of the “WHO Global Strategy on Human Resources for Health: Workforce 2030” www.who.int/hrh/resources/glob-strat-hrh_workforce2030.pdf?ua=1

Background

The Millennium Development Goals (MDGs) with the end-point of 2015 have been a powerful force in maintaining political support for health development because of the clarity of the objectives and measurable targets. The post-2015 development agenda has been driven by the United Nations (UN) High-level Panel of Eminent Persons. This High-level Panel received a report from a UN System Task Team, which set out a broad framework for post- 2015, with four pillars: inclusive economic development; environmental sustainability; inclusive social development - including health; and peace and security, underpinned by human rights, equality and sustainability.1 Ultimately this work led to the development, and formal endorsement, at UN meeting on 25 September 2015, of the Sustainable Development Goals.2 There is no doubt that the SDG agenda will provide the investment framework for the next 15 years.

The SDG agenda addresses many of the “unfinished business” of the MDGs and takes the new health landscape into account. While keeping the health MDG targets, the growing challenge of NCDs and their risk factors have also been included, with clear targets and indicators being developed.3 With the formal approval of the SDG goals and targets, the WHO Global Strategy on Human Resources for Health: Workforce 2030 will provide concrete recommendations and ideas on how to achieve these targets at a more technical level.

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Sustainable Development Goals (SDGs)

For 15 years, the MDGs became the focus of the funding priorities for work with developing countries and the targets against which progress in world health was largely measured. They quickly a major global focus and spawned some very influential and now very large health care organisations such as GAVI (immunisations), the Global Fund and UNAIDS (HIV/AIDS and other infectious diseases); and increased prominence for organisations such as UNFPA (maternal health).

The next 15 year strategy for the UN is embodied in the SDGs and is well underway, having commenced in Rio in 2012, and formally adopted in 2015.2 The goals and targets will be followed-up and reviewed using a set of global indicators. These will be complemented by indicators at the regional and national levels which will be developed by member states, in addition to the outcomes of work undertaken for the development of the baselines for those targets where national and global baseline data does not yet exist. The global indicator framework, to be developed by the Inter Agency and Expert Group on SDG Indicators, will be agreed by the UN Statistical Commission by March 2016 and adopted thereafter by the Economic and Social Council and the General Assembly, in line with existing mandates. This framework will be simple yet robust, address all SDGs and targets including for means of implementation, and preserve the political balance, integration and ambition contained therein.

It is critical that the nursing profession understands the importance and potential impact of the SDGs and, having already missed the conversations related to the setting of the goals and targets,3 we must ensure we are in at the beginning of the process of determining the indicators by which progress will be measured. If the indicators chosen are not sensitive to nursing’s input and impact then the profession risks invisibility for the 15 years span, 2016-2030.

There are some very important distinctions between the MDGs and SDGs. There were only eight MDGs and nursing saw itself as explicitly relevant to three: MDGs 4 Reduce Child Mortality; MDG 5 Improve Maternal Health; and MDG 6 Combat HIV/AIDS, Malaria and other diseases. The focus of the MDGs was explicitly on developing countries.

The SDGs are quite different. ALL countries, irrespective of their income status, are to be involved, as it is acknowledged that even in the high income countries there are great areas of inequality and the actions of high income countries have direct global impact effecting future sustainability.

The Official Agenda for Sustainable Development adopted on 25 September 20152 has 92 paragraphs, with the main paragraph (51) outlining the 17 Sustainable Development Goals (Appendix 1) as follows:

1. End poverty in all its forms everywhere 2. End hunger, achieve food security and improved nutrition and promote sustainable

agriculture[ 3. Ensure healthy lives and promote well-being for all at all ages 4. Ensure inclusive and equitable quality education and promote lifelong learning

opportunities for all 5. Achieve gender equality and empower all women and girls 6. Ensure availability and sustainable management of water and sanitation for all 7. Ensure access to affordable, reliable, sustainable and modern energy for al 8. Promote sustained, inclusive and sustainable economic growth, full and productive

employment and decent work for all

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9. Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation

10. Reduce inequality within and among countries 11. Make cities and human settlements inclusive, safe, resilient and sustainable 12. Ensure sustainable consumption and production patterns 13. Take urgent action to combat climate change and its impacts 14. Conserve and sustainably use the oceans, seas and marine resources for

sustainable development 15. Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably

manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss

16. Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels

17. Strengthen the means of implementation and revitalize the global partnership for sustainable development

As noted above, there is one health related goal: Goal 3 “Good Health and Well-being: ensure heathy lives and promote well-being at all ages”, and this has nine sub-goals or targets (See Appendix II). However, as seen above, many of the others SDGs relate to health, not the least being Goal 6 “clean water and sanitation” which is inherently also linked to Goal 13 “climate action” particularly for our Island and Delta countries. This underlines the intent of the SDGs which is that they are deliberately “integrated and indivisible and balance the three dimensions of sustainable development”: economic, social and environmental.2 Other SDG targets that directly impact health

• Eliminate all forms of violence against all women and girls in the public and private spheres, including trafficking and sexual and other types of exploitation

• Significantly reduce all forms of violence and related death rates everywhere • End abuse, exploitation, trafficking and all forms of violence against and torture of

children • By 2030, end hunger and ensure access by all people, in particular the poor and

people in vulnerable situations, including infants, to safe, nutritious and sufficient food all year round

• By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons

• By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations

The infrastructure is well is in place to tackle the first three goals as they were carried over from the MDGs. However, nursing’s potential role with NCDs, with substance abuse, with traffic accidents and injuries, sexual and reproductive health services, affordable, accessible models of care, and environmental safety are to be convincingly made to our governments and our impact accounted for explicitly in the indictors for each of these areas. We have evidence and must therefore produce it in a compelling locally relevant story. Each country is to develop their own exact accountable target so the opportunity for local influence exists.

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As of August 2015, there were 169 proposed targets for these goals and 304 proposed indicators to show compliance. 3

For further information on the SDGs, click on this link - a one hour briefing for journalists on the SDGs.

http://kff.org/global-health-policy/event/web-briefing-for-media-what-do-the-sustainable-development-goals-mean-for-global-health/

WHO Global Strategy on Human Resources for Health: Workforce 20304

The Global Strategy was developed in response to a resolution passed at the 2014 World Health Assembly (WHA) which recognised the development of the SDGs and the importance of a global HRH strategy to support this work. The draft strategy builds upon global evidence and experience, as well as broad-based consultation in the period 2013-2015 with experts at the global, regional and national level, and has been informed by thematic papers, related global guidelines, policy commitments, regional strategies and initiatives. ICN was actively involved throughout this process, participating in the thematic work groups and commenting throughout the drafting of the Strategy.

ICN encourages NNAs to become familiar with the document given its future relevance to the SDGs and the development agenda for the next 15 years.

As noted, the document starts with a “Vision” statement of the Global Strategy on HRH which states that it seeks to:

“Accelerate progress towards Universal Health Coverage and the Sustainable Development Goals by ensuring equitable access to skilled and motivated health worker within a performing health system.”4

The supporting overall goal further elaborates this statement by identifying that, “ensure(ing) availability, accessibility, acceptability and quality of the health workforce through adequate investments and the implementation of effective policies at national, regional and global levels, for ensuring healthy lives for all at all ages, and promoting equitable socio-economic development through decent employment opportunities.” This section is followed by a series of supporting principle statements. Equitable access, skilled and motivated health worker, and a performing health system are easily understood as essential building blocks for achieving improved health outcomes, despite the difficulties in achieving these. As well it is important to reflect upon what the meaning and significance of the words Universal Health Coverage and Sustainable Development Goals.

Universal Health Coverage (UHC): The WHO definition of UHC is “to ensure that all people obtain the health services they need without suffering financial hardship when paying for them. This requires:

• a strong, efficient, well-run health system; • a system for financing health services; • access to essential medicines and technologies; • a sufficient capacity of well-trained, motivated health workers.”6,7

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There is now international agreement that not only are catastrophic healthcare costs devastating for individuals and families but that they have a highly negative impact on country level productivity and economics. There are many different ways in which countries are seeking to provide a form of safety net for people, but, whatever the strategy, the goal is the prevention of the health related financial hardship.

The next sections of the Global HRH Strategy identify four objectives with targets and supporting policies. Reading this section of the Global Strategy document carefully, it is important to consider how this relates to your country and your countries specific positioning.

How can nursing assist its government to determine its targets and then to meet them?

The objectives are:

1. Optimize the existing workforce in pursuit of the SDGs and UHC (e.g. education, employment, retention)

2. Anticipate future workforce requirements by 2030 and plan the necessary changes (e.g. a fit for purpose, needs-based workforce)

3. Strengthen individual and institutional capacity to manage HRH policy, planning and implementation (e.g. migration and regulation)

4. Strengthen the data, evidence and knowledge for cost-effective policy decisions (e.g. Minimum Data Set + National Health Workforce Accounts)

The Strategy ends with two sections that identify the roles for both the WHO Director General and NGO and other stakeholders to support the work. Again, it is important for NNAs to reflect upon what this means to your country and what role you could play.

Steps in Formal Adoption of WHO Global Strategy on HRH: Workforce 2030

The consultation process by WHO on the Global Strategy has followed their normal governance process: online public consultations were held in July-August 2015; Member States consultation at WHO Regional Committee meetings in Sept-Nov 2015; EB discussion in January 2016; and WHA formal adoption in May 2016.

The first two steps in this process have been completed. ICN submitted an online commentary on the strategy. This was shared with all NNAs who were encouraged to participate. As well, ICN co-hosted with WHO, a formal consultation as part of the CNR in Korea in June 2015.

WHO staff are currently redrafting the document based upon these consultations. A revised version of the Global Strategy for HRH: Workforce 2030 will be discussed by the EB of the WHO at its January 2016 meeting and considered at the WHA in May 2016.

As noted above, the input to WHO at this stage is through the country and regional meetings and representations, hence the importance for all national nursing associations to be knowledgeable about the process and informed about the evidence which demonstrates nursing’s contribution to meeting the vision and goals of the WHO and making this information available to their country representatives, where possible urging participation of senior nurses with country delegations to WHA in May 2016.

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Role of NNAs and Nursing

The role of nursing in such a strategy is of utmost importance to ICN and the more than 16 million nurses practicing worldwide.8 As noted throughout this document, ICN has been actively involved with WHO throughout the development process of this Strategy. However ICN members have an important role to play in ensuring that nursing voices are heard throughout the development process. It is their Ministries of Health who participate as members of WHO and have the opportunity to comment at the WHO Executive Board meeting in January 2016, and the WHA in May when the strategy will be brought for final endorsement.

As the face and national voice of nursing in the country, NNAs have a tremendous opportunity to advocate and reinforce the critical role of nurses in the development of quality health policy and the effective and efficient redesign of health systems that increase access and deliver effective health interventions. As such, NNAs are the conscience and moral compass of the profession to whom individual nurses and the public looks to for guidance and leadership on vital health issues and policies. These issues and policies include access to care, quality of care, patient safety, and safe working environments. Healthcare financing underpins all these issues.8,9

ICN Support for NNAs

The WHO under the current Director General, Dr Margaret Chan, has become very focused on evidence based policy. Being abreast of the evidence in relation to human resources for health and its impact on patient and population outcomes will enable NNAs to assist your government in meeting its targets through nursing. This is a leadership opportunity that is important not to miss.

With this in mind, ICN is preparing a series of policy briefs, using nursing evidence, which NNAs and ICN would use to brief their governments and other stakeholders about the essential contribution of nursing to the global HRH strategy succeeding and to achieving the SDGs for our collective sustainable development.

About ICN The International Council of Nurses (ICN) is a federation of more than 130 national nurses associations representing the millions of nurses worldwide. Operated by nurses and leading nursing internationally, ICN works to ensure quality nursing care for all and sound health policies globally.

About the Author

Professor Jill White, Dean Emerita, Professor of Nursing and Midwifery, Faculty of Nursing and Midwifery, University of Sydney, Australia. Senior Fulbright Scholar 2015, School of Nursing, University of Pennsylvania. Senior Scholar in Residence ICN, May-June 2015, Geneva. Professor White has extensive international experience, most recently in Tonga and Vietnam. She was the founder of the UTS WHO Collaborating Centre and facilitated the formation of the South Pacific Chief Nursing and Midwifery Officers Alliance.

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References

1. World Health Organization (2013). World Health Report. Research for Universal Health Coverage. Retrieved from: http://apps.who.int/iris/bitstream/10665/85761/2/9789240690837_eng.pdf

2. United Nations General Assembly (2015) Transforming our world: the 2030 agenda for sustainable development. A/70/L.1, 18 September.

3. World Health Organization (2012). Health Indicators for Sustainable Development Goals. Geneva: WHO. Retrieved from: www.who.int/hia/health_indicators/en/.

4. Global Health Workforce Alliance & WHO (2015) Health Workforce 2030 Towards a global strategy on human resources for health: a synthesis paper of the thematic working groups. Geneva: GHWA/WHO.

5. World Health Organization (2014). Global Coalition Calls for Acceleration of UHC. Geneva: WHO. December 12. Retrieved at: www.who.int/universal_health_coverage/en

6. ICN/World Bank (2014) Strengthening Community and Frontline Health Workers for universal Health Coverage: Event Summary. July. Geneva. Retrieved at: www.nurse.or.jp/nursing/international/icn/report/pdf/2014m/08-06.pdf.

7. Institute of Medicine (2011) The Future of Nursing: leading change, advancing health. Washington, DC: The National Academic Press.

8. ICN (2015) Nursing a Force for Change: Care effective, cost effective. Geneva: ICN.

9. World Health Organization (2003) Investing in Health: a summary of the findings of the Commission on Macroeconomics and Health. Geneva: WHO CMH Support Unit.

10. World Health Organization (2011) Strategic Directions for Strengthening Nursing and Midwifery Services 2011-2015. Geneva: WHO.

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APPENDIX I SUSTAINABLE DEVELOPMENT GOALS:

http://www.un.org/sustainabledevelopment/sustainable-development-goals/

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APPENDIX II Goal 3. Targets. Ensure healthy lives and promote well-being for all at all ages 3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live

births 3.2 By 2030, end preventable deaths of newborns and children under 5 years of age,

with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under 5 mortality to at least as low as 25 per 1,000 live births

3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases

3.4 By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being

3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol

3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents 3.7 By 2030, ensure universal access to sexual and reproductive healthcare services,

including for family planning, information and education, and the integration of reproductive health into national strategies and programmes

3.8 Achieve universal health coverage, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all

3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination

3a Strengthen the implementation of the World Health Organization Framework

Convention on Tobacco Control in all countries, as appropriate 3b Support the research and development of vaccines and medicines for the

communicable and non-communicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all

3c Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States

3d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks http://www.un.org/ga/search/view_doc.asp?symbol=A/70/L.1&Lang=E

UN General Assembly, 18 September 2015.

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ICN Policy Brief

Nursing Leadership in Primary Health Care for the achievement of Sustainable Development Goals and Human Resources for Health Global

Strategies Authors: Gail Tomblin-Murphy, RN, PhD and Annette Elliott Rose, RN, PhD Background The purpose of the paper is to provide a summary of relevant literature concerning nursing leadership in strengthening primary health care to support the Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC) worldwide. This paper should be read in relation to the “WHO Global Strategy on Human Resources for Health: Workforce 2030” Primary Health Care and Universal Health Coverage The classic definition for Primary Health Care (PHC) is “…essential health care based on practical, scientifically sound and socially acceptable

methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.”1

The WHO model of PHC is focused on better health for all using the following key elements: reducing exclusion and social disparities in health; organizing health services around people’s needs and expectations; integrating health into all sectors; pursuing collaborative models of policy dialogue; and increasing stakeholder participation.2 Universal health coverage (UHC) has become the internationally agreed objective of health and development policy. UHC aims to ensure that all people can use the promotive, preventive, curative, rehabilitative and palliative health services that are of sufficient quality, while at the same time ensuring that the use of these services does not cause financial hardship to the consumers.3 To this end, it is important to remember that PHC is the preferred and effective

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means of delivering essential health services at a cost which governments and communities can afford.4 A national healthcare system is more effective when it is based on PHC encompassing a range of publicly funded essential and universally accessible and equitable health services to the population. Strategies for Strengthening Primary Health Care Strengthening PHC continues to be a focus of health system reform worldwide.4, 5, 6, 7, 8, 9, 10 Both peer-reviewed and non-peer reviewed papers include several key messages to improve PHC. These include: the need for a focus on the social determinants of health; transparent and accountable funding processes; improved access to health services supported by appropriate information technology; and interprofessional practice where quality and outcomes are regularly monitored.11,12 Much of the health re-design that is recommended focuses on models that embrace interprofessional education and practice with health team members who are supported to practice to full scope and who understand each other’s roles.13,14,15 For many healthcare providers, practicing to full scope and being engaged with health colleagues, increases autonomy,16 improves practice satisfaction17 and improves recruitment and retention.18 Evidence also suggests that healthcare should be designed and delivered to support patient- and family-centered health care.19,20 Optimization of the Nursing Role in Primary Health Care Nursing full scope practice in team-based primary care has been found to be cost effective and improves quality of care, increased patient satisfaction, access and equity, particularly in underserviced areas and populations.21,22,23 In many PHC settings, having nurses as full members of the PHC team is essential to meet the complex health and social needs of populations.24, 25, 26 PHC delivery by nurses, including nurse practitioners for acute and episodic care, chronic disease management and practice operations resulted in improved quality of care, efficiency and decreased cost. Maximizing the benefit of nurses practicing in PHC requires a commitment to progressive policy regarding funding and public awareness, competency-based nursing and interprofessional education and the optimization of the nurses role in PHC with comprehensive process and outcome measures.27,28 Additionally, authors of a Cochrane review found that depending on the context of care, appropriately educated nurses provide care comparable to primary care physicians with similar patient outcomes.29

Nurses are educated with a holistic lens so that all facets of a person’s health and well-being are considered when planning and delivering care.30 With increasing focus on the social determinants of health,31 nurses are prepared to provide care based on that broader understanding of health. Nursing education also promotes developing therapeutic relationships with patients and families to fully understand their stories and life contexts in order to individualize care plans and assist people in navigating the health and social systems.32 However, current models of health delivery still tend to focus primarily on the treatment of illness,33 rather than focusing on other key social determinants of health. In remote communities and/or in low-middle income countries, much of the care delivered at the local level depends upon the expertise of community health workers or nursing assistants.34,35 Nurses and nursing play an important role in supporting their colleagues working in communities through advocacy, mentorship, collaboration and by recognising the important contribution of nursing assistants and community health workers in maintaining local services.36

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Nursing Leadership in PHC In addition to being practice leaders, nurses at the organisational and system levels are leading strategic conversations about health system transformation in PHC. As well, national nursing associations and international organisations, such as ICN, are strong advocates for the strengthening of PHC through health system change based on the needs of populations11, 34, 35,

37 and focused on the SDGs and UHC for all.38 It requires change that is evidence-informed, gender-focused and with a shift from predominantly hospital-based care to care in the community and home.39 Primary Health Care, Nursing and the Global Strategy on Human Resources for Health The overall vision of the HRH workforce strategy is to ensure equitable access to a skilled health workforce within a performing health system with progress towards UHC and the SDGs.39 Based on a broad definition of health and with the aim to provide quality health services, the goal of the strategy is to ensure that services are accessible and available but also acceptable for all people across the lifespan. Using a population, needs-based approach that is person-centered and collaborative that also considers gender and safety issues for providers, the Strategy focuses on four main objectives: improving data; implementing evidence-based policy; building effective leadership and governance to support HRH; and investing in approaches that are needs-based, consider the health labour market and maximize employment and economic growth. Generally, the Strategy recognises the importance of strengthening services and care at the local level by creating tangible targets for the redistribution of healthcare workers; the creation of infrastructure for data acquisition and sharing; economic investment in the health workforce; and institutional support for collaboration across sectors. From a PHC perspective, the Strategy focuses on attaining UHC with efficient and effective models of PHC where diversity of skill mix is paramount to meet health needs and there are clear, integrated connections to social services and advanced/specialized care.39 The HRH Strategy aligns with current nursing and midwifery strategies, which focus on person-centered collaborative action that optimise and maximise nursing roles, including advanced practice nurses, to meet health needs. Such action is supported by effective policy and aimed at meeting global goals and targets such as the SDGs and UHC.40 Strategies and Key Messages for Policy-setters to Strengthen PHC

A move from a dominant, illness-focused system to one that also includes preventative services and health promotion care is required. Nursing and nurses are well positioned to lead a shift in thinking, in practice and in policy, which supports a broader understanding of health.

Nurses and nursing are leaders both at the system level and ‘on the ground’ in supporting colleagues who provide PHC in remote and under-serviced areas such as the community health workers and nursing assistants in low and middle-income countries.

Nurses practicing to full scope can provide both acute/episodic care as well as effective chronic disease management. Optimal use of nurses in PHC improves access to care, particularly for vulnerable populations, including those living in rural areas.

In an effort to meet the SDGs for 2016-2030 and provide UHC, a diverse health workforce working in teams with the skills and competencies to meet current population health needs is required.

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As outlined in the Global HRH Strategy, global investments in the health workforce are currently not sufficient to support health or the broader social systems. Therefore, a change in the planning, education, deployment, utilization and recruitment and retention strategies for healthcare workers is needed.39 Such a change includes strengthening PHC by ensuring nurses are key care team members and leaders for health system change.

Interprofessional education is vital to addressing the lack of knowledge providers have about other healthcare providers. It also teaches different care providers how to negotiate issues of shared scope and knowledge as well as decision-making.11, 41, 42 The key is to not only have interprofessional education programmes but also to have interprofessional practice settings to support this new way of learning about how to work together.43,44

Nurses and nursing are leaders at the national and global decision-making tables by supporting a strengthened PHC system that is evidence-based, collaborative, focused on the needs of people and that promotes equitable access to UHC.

About ICN The International Council of Nurses (ICN) is a federation of more than 130 national nurses associations representing the millions of nurses worldwide. Operated by nurses and leading nursing internationally, ICN works to ensure quality nursing care for all and sound health policies globally. About the Authors Gail Tomblin-Murphy, Professor, School of Nursing, Faculty of Health Professions and Community Health & Epidemiology, Faculty of Medicine, Dalhousie University and Director, WHO/PAHO Collaborating Centre Health Workforce Planning and Research, School of Nursing, Dalhousie University. Annette Elliott Rose, Junior Scholar, WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, School of Nursing, Dalhousie University and Perinatal Nurse Consultant, Reproductive Care Program of Nova Scotia.

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References

1. World Health Organization (1978). Declaration of Alma-Ata International Conference on Primary Health Care, Alma-Ata, USSR. Retrieved from http://www.who.int/publications/almaata_declaration_en.pdf

2. World Health Organization (2015). Primary Health Care. Retrieved from http://www.who.int/topics/primary_health_care/en/

3. World Health Organization (2013). World Health Report. Research for Universal Health Coverage. Retrieved from: http://apps.who.int/iris/bitstream/10665/85761/2/9789240690837_eng.pdf

4. World Health Organization (2008). Primary Health Care. Now More than Ever. Retrieved from: http://www.who.int/whr/2008/en/

5. Hutchison, B., & Glazier, R. (2013). Ontario’s primary care reforms have transformed the local care landscape, but a plan is needed for ongoing improvement. Health Affairs, 32(4), 695-703.

6. Hutchison, B., Levesque, F., Strumpf, E., & Coyle, N. (2011). Primary health care in Canada: systems in motion. Milbank Quarterly, 89(2), 256-288.

7. Starfield, B. (2007). Primary care in Canada: coming or going? Healthcare Papers, 8(2), 58-62. 8. Strumpf, E., Levesque, J. F., Coyle, N., Hutchison, B., Barnes, M., & Wedel, R. J. (2012).

Innovative and diverse strategies toward primary health care reform: lessons learned from the Canadian experience. The Journal of the American Board of Family Medicine, 25 (Suppl 1), S27-S33.

9. Health Council of Canada (2009). Strengthening Primary Healthcare in Canada evidence brief. Retrieved from: http://www.conseilcanadiendelasante.ca/tree/2.41.5-Strengthening_Primary_Healthcare_in_Canada_evidence-brief_2009-05-11.pdf

10. Romanow, R.J. (2002). Building on Values: the Future of Health Care in Canada, Final Report, November 2002. Commission on the Future of Health Care in Canada. Retrieved from http://www.cbc.ca/healthcare/final_report.pdf

11. Tomblin Murphy, G., Birch, S., MacKenzie, A., Alder, R., Lethbridge, L., & Little, L. (2012). Eliminating the shortage of registered nurses in Canada: an exercise in applied need-based planning. Health Policy, 105 (2-3), 192-202.

12. Van Soeren, M., Hurlock-Chorostecki, C., Pogue, P., & Sanders, J. (2007). Primary healthcare renewal in Canada: a glass half empty? Healthcare Papers, 8(2), 39-44.

13. Barrett, J., Curran, V., Glynn, L., & Godwin, M. (2007). CHSRF Synthesis: Interprofessional Collaboration and Quality Primary Health Care. Canadian Health Services Research Foundation. Retrieved from http://www.chsrf.ca/Migrated/PDF/SynthesisReport_E_FINAL.pdf

14. Frenk, J., Chen, L., Bhutta, Z. A., Cohen, J., Crisp, N., Evans, T., ... & Zurayk, H. (2010). Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet, 376 (9756), 1923-1958.

15. Gilbert, J. (2013). Interprofessional-education, learning, practice and care. Journal of Interprofessional Care, 27(4), 283-285.

16. Kramer, M. & Schmalenberg, C. (2008).The practice of clinical autonomy in hospitals: 20 000 nurses tell their story. Critical Care Nurse, 28(6), 58-71.

17. O’Brien-Pallas, L., Duffield, C. & Hayes, L. (2006). Do we really understand how to retain nurses? Journal of Nursing Management, 14(4), 262-270.

18. Tomblin Murphy, G., Alder, R., Birch, S., MacKenzie, A. & Lethbridge, L. (2010). Needs-based Health Human Resource Planning for Nurses in Ontario. Report submitted to the Ontario Ministry of Health and Long Term Care. London, ON: University of Western Ontario.

19. Epstein, R. M., & Street, R. L. (2011). The values and value of patient-centered care. The Annals of Family Medicine, 9(2), 100-103.

20. Scherger, J. E. (2009). Future vision: is family medicine ready for patient-directed care. Family Medicine, 41(4), 285-8.

21. Jacobson, P. M. (2012). Evidence synthesis for the effectiveness of interprofessional teams in primary care. Canadian Health Services Research Foundation.

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22. Health Quality Ontario. Specialized nursing practice for chronic disease management in the primary-care setting: an evidence-based analysis. Ont Health Technol Assess Ser [Internet]. 2013 September;13(10):1–66. Retrieved from: http://hqontario.ca/en/documents/eds/2013/full-report-OCDM-specialized-nursing.pdf

23. Martin‐Misener, R., Downe‐Wamboldt, B., Cain, E. & Girouard, M. (2009). Cost‐effectiveness and

outcomes of a nurse practitioner‐paramedic‐family physician model of care: the Long and Brier Islands study. Primary Health Care Research and Development, 10, 14‐25.

24. Iglesias, B., Ramos, F., Serrano, B., Fabregas, M., Sánchez, C., García, M. J., ... & Esgueva, N. (2013). A randomized controlled trial of nurses vs. doctors in the resolution of acute disease of low complexity in primary care. Journal of Advanced Nursing, 69(11), 2446-2457.

25. Clark, C. E., Smith, L. F., Taylor, R. S., & Campbell, J. L. (2011). Nurse‐led interventions used to

improve control of high blood pressure in people with diabetes: a systematic review and meta‐analysis. Diabetic Medicine, 28(3), 250-261.

26. Martínez-González, N. A., Rosemann, T., Tandjung, R., & Djalali, S. (2015). The effect of physician-nurse substitution in primary care in chronic diseases: a systematic review. Swiss Medical Weekly, 145.

27. Russell, G. M., Dahrouge, S., Hogg, W., Geneau, R., Muldoon, L., & Tuna, M. (2009). Managing chronic disease in Ontario primary care: the impact of organizational factors. The Annals of Family Medicine, 7(4), 309-318.

28. Smolowitz, J., Speakman, E., Wojnar, D., Whelan, E. M., Ulrich, S., Hayes, C., & Wood, L. (2015). Role of the registered nurse in primary health care: Meeting health care needs in the 21st century. Nursing Outlook, 63(2), 130-136.

29. Laurant, M., Reeves, D., Hermens, R., Braspenning, J. Grol, R. & Sibbald, B. (2005). Substitution of doctors by nurses in primary care. Cochrane Database Systematic Review, 18 (2).

30. McEvoy, L. & Duffy, A. (2008). Holistic practice–a concept analysis. Nurse Education in Practice, 8(6), 412-419.

31. Marmot, M., Friel, S., Bell, R., Houweling, T. A., Taylor, S., & Commission on Social Determinants of Health. (2008). Closing the gap in a generation: health equity through action on the social determinants of health. The Lancet,372(9650), 1661- 1669.

32. Arnold, E. C., & Boggs, K. U. (2015). Interpersonal relationships: Professional Communication skills for nurses. Elsevier Health Sciences.

33. Lantz, P., Lichtenstein, R. & Pollack, H. (2007). Health policy approaches to population health: The limits of medicalization. Health Affairs, 26 (5), 1253-1257.

34. Tomblin Murphy G, Goma F, MacKenzie A, Bradish S, Price S, Nzala S, Elliott Rose A, Rigby J, Muzongwe C, Chizuni N, Hamavhwa D, Carey A. (2014). A scoping review of training and deployment policies for human resources for health for maternal, newborn, and child health in rural Africa. Human Resources for Health. 12:72. (Published on-line, December 16, 2014 as doi:10.1186/1478-4491-12-72), 1-15. http://www.human-resources-health.com/content/12/1/72.

35. Tomblin Murphy, G., Goma, F, MacKenzie, A., Bradish, S., Price, S., Nzala, S., Elliott Rose, A., Rigby J, Muzongwe C, Chizuni N, Carey A, Hamavhwa D. (2015). Training and deploying human resources for health for maternal, newborn, and child health in rural Africa: an in-depth policy analysis. The Journal of Global Health Care Systems, North America, 5, Jun. 2015. Available at: <http://www.jghcs.info/index.php/j/article/view/407>. Date accessed: 02 July 2015.

36. Dick, J., Clarke, M., Van Zyl, H., & Daniels, K. (2007). Primary health care nurses implement and evaluate a community outreach approach to health care in the South African agricultural sector. International Nursing Review, 54(4), 383-390.

37. Shamian, J. (2015). Global voice, strategic leadership and policy impact: global citizens, global nursing.

38. Shamian, J., Murphy, G. T., Rose, A. E., & Jeffs, L. (2015). Human resources for health: a new narrative. The Lancet, 386(9988), 25-26.

39. World Health Organization (2015). Global Strategy on Human Resources for Health: Workforce 2030. Retrieved from: http://who.int/hrh/resources/glob-strat-hrh_workforce2030.pdf?ua=1

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40. World Health Organization (2010). Nursing and Midwifery Services. Strategic Directions 2011-2015. Retrieved from: http://apps.who.int/iris/bitstream/10665/70526/1/WHO_HRH_HPN_10.1_eng.pdf

41. Barr, H. (2009). Interprofessional education. A practical guide for medical teachers. Third edition. Edinburgh: Churchill Livingstone.

42. Gilbert, J., Yan, J., & Hoffman, S. J. (2010). A WHO report: framework for action on interprofessional education and collaborative practice. Journal of Allied Health, 39(Supplement 1), 196-197.

43. Reeves, S., Zwarenstein, M., Goldman, J., Barr, H., Freeth, D., Hammick, M., & Koppel, I. (2008). Interprofessional education: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews, 1.

44. Herbert, C. P. (2005). Changing the culture: Interprofessional education for collaborative patient-centred practice in Canada. Journal of Interprofessional Care, 19(S1), 1-4.

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ICN Policy Brief

Quantity, Quality and Relevance of the Nursing Workforce to Patient Outcomes

Authors Jill White, AM RN RM MEd PhD; Allison Squires, PhD, RN, FAAN; and Walter Sermeus, PhD,

RN, FEANS.

Purpose The purpose of this policy brief is to provide guidance on the relationships between quality and safety of patient care, patient and population outcomes and nursing. Evidence now demonstrates the best patient and population health outcomes occur when there is the right mix of health workers in the right place, at the right time with the right resources needed to perform their jobs, and management support to enable them to work effectively to their full scope of practice. This brief summarizes the evidence concerning the impact of a well-educated nursing workforce on positive patient quality outcomes and discusses the implications of this evidence for country level human resources for health (HRH) planning. This paper should be read in relation to the zero draft of the “Global Strategy on Human Resources for Health: Workforce 2030”. Background With increasing consistency, research demonstrates that the safety and quality of care delivery is enhanced when nurses have an appropriate level of education, the resources and the support to enable them to provide high quality of care. Nurses witness and experience the consequences of health policy decisions, both intended and unintended on patients and care practice within health settings. The over 16 million nurses worldwide see the effects of health and social policies on patients, families and communities’ access to care, direct and indirect costs of healthcare and the consequent effects of policy changes on the access, affordability, appropriateness and quality of care provision. 1, 2, 3, 4, 5, 6, 7 Nurses make up the largest proportion of healthcare professionals, providing over 80% of all care episodes worldwide.8 The work of nurses and their ability to provide safe and effective care is inextricably impacted by policy effecting organisational funding, staffing, access to reimbursement, scope of practice and the competing service demands of vertical programmes. Nurses provide the majority of care in underserved communities which lack affordable access to all levels of healthcare, whether rural

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and remote communities of high income countries or all communities in low income countries.9,

10, 11, 12 They coordinate the care of all health professional groups in acute care facilities and are often responsible for ensuring safe practice. Evidence linking Nursing and Positive Patient Outcomes Adequate registered nurse staffing has been demonstrated to decrease deaths, injury and permanent damage.13,14, 15, 16,17, 18 It is also implicated in prevention of healthcare-acquired-infections which were estimated to cause 99 thousand deaths annually in the USA and cost an estimated $US 6.5 billion in 2004 in the US alone.19 Evidence demonstrates nurses provide cost-effective, accessible quality care with greater or equal clinical outcomes and patient satisfaction where local policies and politics enable them to offer these services.20, 21 Nurse practitioner studies internationally have repeatedly found the effectiveness of nurse-led care in community services, including the findings of a Cochrane Collaboration systematic review.22,23 Evidence is clear that nurses have a significant role to play in the community based management of non-communicable diseases, and patient access to appropriate treatment is enhanced by nurse prescribing.24, 25, 26 An Appropriately Prepared and Available Nursing Workforce To assure achievement and sustainability of affordable care for all, i.e. universal healthcare coverage (UHC), a supportive and enabling environment focused on quality of care is needed to maximise the return on investment made in training, recruitment and retention of nurse in the healthcare workforce.27 The following sections describe the key points of investment that can help inform policymakers for a sustainable nursing workforce that provides quality. Entry Level Education Research shows that more highly educated nurses lead to lower patient mortality, lower complication rates, shorter length-of-stay in hospitals and may lead to lower costs by avoiding the costs of poor quality.

“…a 10% increase in the proportion of nurses holding a bachelor's degree was associated with a 5% decrease in both the likelihood of patients dying within 30 days of admission and the odds of failure to rescue”.28

This research was carried out in the United States and there exists significant variability across countries and across country income levels in the entry to practice educational levels of a nurse. The international aspiration for more effective healthcare delivery is to improve the level of education of nurses in all countries to as close to a bachelor level entry as is possible for the circumstances of the country. This will require collaborative planning between the health and education systems and could lead to creative solutions such as degree completion programmes for nurses with practical or technical education and training. Staffing and Logistic Support Nurses need qualified and competent personnel to work with in order to ensure quality care is provided. Careful and effective health workforce planning is required to meet the goal of scaling up sufficient numbers of a competent and diverse nursing workforce. Ensuring nurses have the necessary competencies and scope of practice that allows them to effectively promote health and provide care is needed if we are to ensure equitable access to quality health services.

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In hospital settings, there are no universal nurse staffing standards as this depends on many contextual factors such as case-mix, patient acuity, scope of practice, etc. Countries should define safe staffing levels for different types of nursing wards, as well as for primary care and other care delivery sites. There is a growing body of evidence from the research group led by Linda Aiken on safe staffing ratios in the multi-country studies. Needleman (2015) summarizes much of this staffing outcomes research in his review in the special edition of Nursing Economics.29 Notably, in one study safe staffing levels were estimated to save USD$6 billion due to savings from reduced medical errors and the added costs of more nurses paid for themselves from the savings with about USD$1 billion to spare.30 Finally, for optimal contribution to health services, nurses require collaborative support personnel who can facilitate their roles and care delivery that they may manage or supervise. These may include nursing assistants or community health workers, depending on the context of care. Collaborative support personnel can help offset high care demands that result from nursing shortages. They may also help organisations reach the minimum staffing goals. Management Support & Development Research demonstrates that nurses leave employers when management is poor.31, 32, 33, 34, 35, 36,

37, 38, 39, 40, 41, 42, 43, 44 Poor management practices include lack of flexible scheduling; lack of support when conflicts arise (especially with physicians); poor supply management; a punitive culture when mistakes are made; and a lack of staff education programmes. This has been the focus of the now significant body of research into what is known as the Magnet hospital studies which explored the characteristics of the facilities where nurses were happy to work and where staff vacancies were low. 45, 46, 47

In capacity building for a sustainable nursing labour market it is important to include nurses in management and leadership training. This will provide managers with the knowledge and skills to develop supportive practice environments for quality care. A supportive work environment where nurses feel their work is recognized; they have support during inter or intra-professional conflict; they are paid regularly; they have a voice in organisational governance; and opportunities for advancement mean that labour markets will become stable enough to produce quality care outcomes. Regulation It is important that effective regulatory frameworks are in place to ensure the protection of the public and in so doing ensure the competence of the entry nurses and their ongoing competence. A recent World Bank report concluded that a lack of regulation has negatively contributed to quality health worker production while obstructive regulations delay health workers entering the labour market.27 Standards for practice, standards for education programmes, codes of ethics and codes of conduct are all part of such a robust regulatory system. Addressing health promotion and supporting self-care, key factors in addressing health coverage, lie within nurses’ scopes of practice. The work environment is also a key aspect of improving patient safety and the quality of health care.

Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health

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policy and in patient and health systems management, and education are also key nursing roles.48.

Regulation is important for accurate workforce data on health professionals and their level of practice authorisation. Further, it is important at country level to be able to ascertain accurate data on the numbers of each health professional classification and data on the within profession specialties in order to plan for workforce future needs. Relationship to the Sustainable Development Goals SDG Goal 1 - No Poverty: Nurses’ economic contributions to a country increase with education and once educated, nurses help to address the health sequelae that emerge from poverty and contribute to poverty fighting efforts. SDG Goal 2 - End Hunger: Nurses play a role in the identification and addressing individuals living in poverty and their associated health risks. SDG Goal 3 - Good Health & Well-Being: Nurses, as the largest health provider, play a significant role in the quality of the country’s health system, both in preventive and health promotion actions and in treating disease and illness. SDG Goal 4 - Quality Education: As demonstrated in the research noted throughout this brief, investments in nursing education have a significant impact on the quality of health care services. A, resulting in higher patient outcomes. SDG Goal 5 - Gender Equality & SDG Goal 10 - Reduced Inequalities: Nurses represent the majority of health workers in a country. Therefore a country nursing workforce plan that includes gender sensitive elements would assist a country in addressing issues of gender and diversity in its health workforce. SDG Goal 8 - Decent Work & Economic Growth: Nurses who work in high quality supportive environments, remain in their positions and their salaries, which often place them solidly in the middle class, contribute to strong economic growth within their communities. SDG Goal 16 - Peace, Justice, & Strong Institutions: Nurses and NNAs recognize the importance of work creating and supporting diverse multicultural workplaces. Connection to WHO Global Strategy on HRH Objective 1: Implement evidence-based HRH policies to optimize impact of current health workforce. The recommendations included in this brief are all derived from an extensive body of international evidence from high, middle and low income countries. Countries that collaborate with their national nursing associations to revise policies so they are based on evidence that optimises patient outcomes are more likely to improve population health and effectively manage health system costs.

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Objective 2: Align with national and global HRH investment frameworks; maximize opportunity for employment creation and economic growth. This brief offers key areas of investment for stakeholders involved in nursing human resources development. By focusing on strategic investment in nursing human resources through educational approaches, policymakers can not only help meet the goals of the WHO HRH framework, but will receive the double benefit of helping meet many of the SDGs. Objective 3: Build capacity of national and international institutions for effective global and national HRH leadership and governance. Investments in the professional institution of nursing are investments in women’s education, economic contributions and development. Strengthening the regulatory capacity of the profession for autonomous accountability will improve standards of education, care, and practice.27 These institutions, however, require capital investments. Said capital does not have to come from government sources alone; it can come from a multiplicity of donors who can help assist the nursing profession in creating and sustaining regulatory institutions. A critical element of governance is knowing exactly how many nurses are in a country. Nursing human resources data should include information that clearly differentiates 1) nurses’ educational levels and 2) place of employment. This data is critical to effective workforce forecasting and resource allocation. Publicly available average salary levels would also help enhance transparency in health system financing and foster economic analyses of the economic contributions of nursing personnel. Objective 4: Ensure HRH efforts and national and global levels are underpinned with credible, reliable and timely information and evidence. By implementing national nursing reports on a regular basis, countries can attract additional resources for investment in nurses. These reports may also facilitate international nursing workforce comparisons that would facilitate partnerships that can help support the work of the profession and improve health outcomes. Key Messages for Policy-makers o With increasing consistency, research demonstrates that the safety and quality of care

delivery is enhanced when nurses have an appropriate level of education, the resources needed to do their work and the support to enable them to work to their full scope of practice

o Entry level nursing education should require a minimum of 12 years of schooling and strive toward the bachelor’s degree as the minimum entry level where possible.

Reduced barriers to employment opportunities will improve with reduced time to hire between graduation and entry into practice in both the public and private sector and help reduce unemployment and underemployment, especially among individuals under 30.

Staffing and logistical support is critical for improving patient outcomes. Innovative staffing models with a varied skill mix can help improve health outcomes. Appropriate staffing levels may also save money through reducing costly medical errors.

Management support & development is necessary for retaining nurses in healthcare organisations and reducing costs associated with turnover, along with providing career advancement opportunities.

Regulation is essential to ensure: 1) quality educational programmes for nurses at all levels; 2) safe work environments; 3) competent practitioners; and most importantly 4) the protection of the public and enhancing the health for all.

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About ICN The International Council of Nurses (ICN) is a federation of more than 130 national nurses associations representing the millions of nurses worldwide. Operated by nurses and leading nursing internationally, ICN works to ensure quality nursing care for all and sound health policies globally.

About the Authors

Professor Jill White, Dean Emerita, Professor of Nursing and Midwifery, Faculty of Nursing and Midwifery, University of Sydney, Australia. Senior Fulbright Scholar 2015, School of Nursing, University of Pennsylvania. Senior Scholar in Residence ICN, May-June 2015, Geneva. Professor White has extensive international experience, most recently in Tonga and Vietnam. She was the founder of the UTS WHO Collaborating Centre and facilitated the formation of the South Pacific Chief Nursing and Midwifery Officers Alliance.

Allison Squires, Assistant Professor and Director of International Education, New York University (NYU) College of Nursing; Research Assistant Professor at NYU School of Medicine, New York, USA. A health workforce capacity building researcher, her work has taken place in 30 countries, most of them low and middle income. She has consulted for the World Bank and Migration Policy Institute (Washington, DC) on various topics around global healthcare labor markets.

Walter Sermeus, Full Professor KU Leuven, Leuven Institute of Healthcare Policy. Sermeus is full professor in health care management and program director for health sciences at KU Leuven. He is also board member of various international organizations. His research interest is on health care organizations, clinical pathways, clinical process innovations and quality improvement. He is also currently Frances Bloomberg Distinguished Visiting Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.

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36. Flynn, L., Liang, Y., Dickson, G. L., & Aiken, L. H. (2010). Effects of nursing practice environments on quality outcomes in nursing homes. Journal of the American Geriatrics Society, 58(12).

37. Flynn, L., Liang, Y., Dickson, G. L., Xie, M., & Suh, D.-C. (2012). Nurses’ practice environments, error interception practices, and inpatient medication errors. Journal of Nursing Scholarship : An Official Publication of Sigma Theta Tau International Honor Society of Nursing / Sigma Theta Tau, 44(2), 180–6.

38. Gunnarsdóttir, S., Clarke, S. P., Rafferty, A. M., & Nutbeam, D. (2009). Front-line management, staffing and nurse-doctor relationships as predictors of nurse and patient outcomes. a survey of Icelandic hospital nurses. International Journal of Nursing Studies, 46(7), 920–7.

39. Manojlovich, M. (2005). Health Policy and Systems: Linking the Practice Environment to Nurses’ Job Satisfaction Through Nurse-Physician Communication. Journal of Nursing Scholarship, 37(5), 367–373.

40. Roch, G., Dubois, C. A., & Clarke, S. P. (2014). Organizational climate and hospital nurses’ caring practices: A mixed-methods study. Research in Nursing and Health, 37(3), 229–240

41. Squires, A., & Juárez, A. (2012). A qualitative study of the work environments of Mexican nurses. International Journal of Nursing Studies, 49(7), 793–802.

42. Tullai-McGuinness, S., Riggs, J. S., & Farag, A. a. (2011). Work environment characteristics of high-quality home health agencies. Western Journal of Nursing Research, 33(6), 767–85.

43. Wade, G. H., Osgood, B., Avino, K., Bucher, G., Bucher, L., Foraker, T., … Sirkowski, C. (2008). Influence of organizational characteristics and caring attributes of managers on nurses’ job enjoyment. Journal of Advanced Nursing, 64(4), 344–53.

44. Walker, K., Middleton, S., Rolley, J., & Duff, J. (2010). Nurses report a healthy culture: results of the Practice Environment Scale (Australia) in an Australian hospital seeking Magnet recognition. International Journal of Nursing Practice, 16(6), 616–23.

45. Clarke SP, Sloane DM, Aiken LH. Effects of hospital staffing and organizational climate on needlestick injuries to nurses. Am J Public Health. 2002;92(7):1115-1119.

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46. Havens DS, Aiken LH. Shaping systems to promote desired outcomes: the Magnet hospital model. J Nurs Adm. 1999;29(2):14-20. http://www.un.org/ga/search/view_doc.asp?symbol=A/70/L.1&Lang=E

47. Scott JG, Sochalski J, Aiken L. Review of Magnet hospital research: findings and implications for professional nursing practice. J Nurs Adm. 1999;29(1):9-19.

48. ICN (2002) Definition of Nursing. Available at:://www.icn.ch/who-we-are/icn-definition-of-nursing/).

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ICN Policy Brief

Contributions of Nursing and Midwifery Enterprises to Achievement of Human Resources for Health Targets and Sustainable Development Goals

Author Marla E. Salmon, ScD, RN, FAAN Purpose Nursing and midwifery enterprises (NMEs) make important contributions to enhancing the reach and impact of health systems in countries around the world. Recent research and global discussions have focused on the capacity of NMEs to also address broader social and economic challenges, including gender equity and poverty reduction. This paper provides a summary of relevant literature and discussions regarding the contributions of nursing and midwifery enterprise in support the Sustainable Development Goals and Universal Health Coverage. This paper should be read in relation to the zero draft of the “WHO Global Strategy on Human Resources for Health: Workforce 2030” Background The wellbeing of women is closely connected to that of their families, communities and society at large. Recognition of this relationship has underpinned longstanding investments in both the global health and international development. Health sector efforts have largely focused on service delivery to women, often relating to reproductive and maternal-child health.1 In contrast, international development investments have focused on women’s empowerment, including widespread support for ownership of enterprise and control of assets; education and training; and larger societal engagement.2 Research demonstrates that specific combinations of the aforementioned contextual factors will influence the health and well-being along with economic opportunities of women.3 The importance of bringing together health and development efforts to maximise health and social gains is reflected in the global Universal Health Coverage (UHC) and the Sustainable Development Goals (SDG) agendas, which require collaboration and innovation across sectors in order to forge progress in achieving their aims. For example, a recent study by Squires et al.4 found that a country’s average level of education explained nearly 50% of both the physician and nurse/midwife-to-population ratio (r2 = 0.49; p = 0.000). Both health worker cadres represent a significant percentage of formally employed females in most countries. In addition, factors such as the growth in chronic disease;5 the plight of female workers;6 and poverty resulting from illness and injury are challenging governments and social investors to find and

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develop innovative models that extend the quality and reach of services, improve the lives of women’s lives and reduce poverty. Bringing together approaches to women’s empowerment from the development sector with health sector community based service delivery holds promise for multiple health and social issues. The growth of such investment in the health sector is already resulting in development of innovative models for community-based service delivery. These approaches rely on nurses, midwives and outreach workers – the majority of whom are women. Collaborations between key stakeholders involved in women’s empowerment have developed promising models for service delivery that have the potential to not only expand the reach and quality of services, but also empower female health workers. An excellent example of these promising models are nursing and midwifery enterprises (NMEs), which are community-level health services delivered through provider practices owned and/or operated by nurses and midwives, often working in collaboration with community health workers and other predominately female frontline workers. Examples of NMEs can be found in countries across income levels.7 NMEs have various corporate structures, including both for profit and not-for-profit, and often serve remote or underserved populations. Payment for services varies, including contracting with governments for service delivery, insurance or self-pay arrangements. NMEs are often organised through cooperatives, networks or franchises, as well as individual, free-standing arrangements. Many NMEs have characteristics that are well aligned with empowerment of women that extend beyond service delivery.1, 8 Among these are opportunities such as ownership of assets; leadership development; education, training and career opportunity; and representation and “voice” in larger community affairs. In 2014, the Institute of Medicine (IOM) convened a Rockefeller Bellagio Center workshop that examined more closely the potential of NMEs to empower women while also strengthening health systems and services. The report of this meeting, Empowering women and strengthening health systems and services through investing in nursing and midwifery enterprise: Lessons from lower income countries,7 and subsequent forums hosted individually by the IOM, World Bank and IPIHD (International Partnerships in Healthcare Delivery) have advanced further discussion of this topic, while also identifying reduction of poverty associated with ill health and injury as a third potential area for NME impact. Insights from these and other discussions point to important potential for NMEs to accelerate progress toward UHC and the Sustainable Development Goals. In addition, the potential for NMEs to serve as “hubs” for training, supervision, career development, and collaboration with Community Health Workers (CHWs) and other frontline health workers was seen as additional means for augmenting their impact on women, health and poverty. Another important dimension of discussions relating to NMEs is the crucial role of governments in creating a context in which NMEs and other innovative approaches to service delivery can help to achieve the goals of national health plans. Investment in the health sector is giving rise to services that are not directly controlled by government. Development of appropriate financing, regulation and administrative processes enabling their alignment is crucial not only for NMEs but also for optimizing the positive impact of health innovation. Connection to WHO Global Strategy on HRH NMEs contributions to WHO’s Global Strategy on HRH are discussed under each of the headings (abbreviated objectives) below:

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Objective 1: Implement evidence-based HRH policies to optimize impact of current health workforce: NMEs can serve as a mechanism for enhancing the impact of nurses, midwives and other health workers. Establishment of NMEs in rural and underserved areas helps to extend the reach and impact of health services, while providing employment, asset ownership and career development opportunities. This may help to recruit and retain nurses and midwives, while also enabling support, training and career development opportunities for other frontline workers, and providing employment and ownership opportunities that may help to retain nurses and midwives in their communities. NMEs can help to address health needs associated with natural disasters, epidemics and other pressing situations.

Objective 2: Align with national and global HRH investment frameworks; maximize opportunity for employment creation and economic growth. NMEs are closely aligned with the advancing national and global HRH agendas and investment frameworks, while also increasing opportunities for employment and economic growth. While enterprise development in the health sector is not new, the idea of its use to achieve triple gains of strengthening health services and systems, improving the lives of female health workers, and reducing poverty associated with lack of appropriate health services7 is relatively recent. The potential for NMEs to serve as focal points for these types of investment holds promise for advancing achievement of this objective. It is important to note that appropriate private and philanthropic investment in NMEs can help to extend the reach of health services without additional government investment beyond payment for services to those without previous access. NMEs can also help governments to develop effective public-private partnerships, given their relatively early stages of development in many countries. Government investment and engagement in NME start-up and incubation can enable incorporation of appropriate agreements, financing, regulation and other supports to ensure access, quality, affordability and strategic alignment of services with national, regional and local planning. These arrangements can help to inform relationships with other health sector enterprise.

Objective 3: Build capacity of national and international institutions for effective global and national HRH leadership and governance. Effective leadership and governance includes representation of women. Because women are so crucial to the delivery of health services, their expertise and voice can benefit governance at all levels. The representation of women in nursing and midwifery, along with other frontline health workers with whom they work, is a crucial dimension of HRH leadership and governance. NMEs provide an important pathway for development of leaders within these organisations; the communities in which they work; the cooperatives, networks and franchises in which many are located; and the government, NGOs and private organisations with which NMEs interface. NMEs provide possibilities for women’s ownership, operation and leadership of health-related enterprise, as well as avenues for advancement of their social, economic and educational opportunities, voice and agency in larger contexts.

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Objective 4: Ensure HRH efforts and national and global levels are underpinned with credible, reliable and timely information and evidence. NMEs that serve as “hubs” for training, supervising, and deploying frontline health workers can help to provide data and information for health planning efforts. Evidence regarding the important contributions of nursing and midwifery to health is well documented across settings. The impact of nursing and midwifery practice arrangements on access and quality of health services, including nurse managed clinics, midwifery practices, home health services, free-standing nursing health stations, and birthing centers is also well documented. As with physician or dentist owned practices, evidence relating to the comparative performance of practices or enterprises owned and/or operated by health professionals is largely anecdotal. NMEs and other types of professionally owned and operated health sector enterprises will benefit from incorporating training of these professionals in leadership and management, which may also contribute to HRH agendas focusing on improved work conditions, service quality, and cost-effectiveness.

Contributions to meeting SDGs NMEs hold promise for directly contributing to eight of the SDGs. Each is discussed below:

SDG 1 - No poverty: NMEs can help to provide access to affordable, accessible and appropriate health services, which can help to reduce the impact of illness and injury on the economic wellbeing of individuals, families and communities.

SDG 3 - Good health and wellbeing: NMEs are largely community-based and well aligned with the goals of UHC. Their capacity to provide affordable, accessible and appropriate services can contribute to good health and wellbeing.

SDG 4 - Quality education: Education and training that prepares women to become nurses and midwives can afford them opportunities for learning otherwise unavailable in some settings. NMEs provide settings in which they can utilise their learning, while also providing training and career development opportunities to other frontline workers.

SDG 5 - Gender equality: Female health workers are at the centre of service delivery in the health sector. Many are unpaid or underpaid. NMEs can provide opportunities for women to advance their educational, economic and social wellbeing through ownership, training and employment.

SDG 8 - Decent work and economic growth: NMEs have the potential to attract investment, provide decent employment, improve health, and reduce health-related poverty – all of which has potential to contribute to economic wellbeing and decent employment.

SDG 10 - Reduced inequalities: NME-associated economic opportunity, poverty reduction, and advancement of women’s wellbeing have the potential to reduce income inequalities and other inequalities.

SDG 17 - Partnerships for the goals: NMEs sit at the nexus of health and development. Their potential gains extend across goals in both sectors and reflect the importance of finding creative approaches to optimising impact, while making wise use of resources.

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Key messages to policy makers NMEs have the potential to achieve important policy goals that include:

Expanding the reach and impact of health systems through use of private and philanthropic investment

Providing cost-effective services to vulnerable, under-served populations, as well as meeting the needs of expanding middle class markets in some settings

Providing opportunities for gains in health, gender equity, poverty reduction, decent employment, strengthening economies

Leveraging the resources and assets of both health and development sectors through accessing aid, investment and support focused on enterprise investment

Enabling greater support and career development opportunity for CHWs and other frontline workers associated with NMEs

Recruiting and retaining nurses and midwives within their communities and countries through opportunities associated with NMEs

Improving the lives of female health workers

Providing opportunities for decent employment and economic wellbeing

Reducing illness and injury-related poverty through improving access to affordable and effective health services

Guidance for National Nursing Associations (NNAs) NNAs can play important roles in shaping the future and impact of NMEs. Deliberately developing and advancing NMEs that aim to advance HRH and SDG targets must be at the centre of this work. It is important that NMEs be viewed as social enterprises in which the betterment of humankind is “hard wired” into this work. NMEs must have close alignment with the work of national health systems, and the aspirations and needs of the communities in which they work. Successful NMEs also depend on the appropriate training and support of nurses and midwives engaged in their development and ensuring sustainability. NNAs will face a number of challenges relating to NMEs. The first is that the public sector may be concerned that NMEs will compete with or erode the capacity of national health systems. NNAs will need to ensure that they help to strengthen national health systems and services. This requires commitment and skill in developing constructive public-private partnerships. It also means developing appropriate organisational, regulatory, quality and financing supports. The second relates to developing the entrepreneurial, leadership and business skills necessary to success of these enterprises. This not only means training and education – it also means developing a professional culture in which social enterprise is viewed as an important way to improve health and wellbeing. The last major challenge relates to professional cultures that isolate nursing and midwifery from other frontline providers, particularly those who are assistive and outreach personnel. CHWs, care assistants, and even those family members who are part of the caring team may not be seen as important partners who are worthy of opportunity and support. Most of these workers are women whose lives can benefit from being valued collaborators and beneficiaries of NMEs’ potential to provide empowerment opportunities and decent employment.

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NNAs can also make important contributions to NMEs through other types of roles in their development. For example, some nursing and midwifery associations have created professional networks for their members, some even providing initial financing, training and peer support. Collective arrangements, like networks, cooperatives and social franchises can afford important supports to their members. About ICN The International Council of Nurses (ICN) is a federation of more than 130 national nurses associations representing the millions of nurses worldwide. Operated by nurses and leading nursing internationally, ICN works to ensure quality nursing care for all and sound health policies globally.

About the Author Marla E. Salmon, Professor of Nursing and Global Public Health, and Senior Visiting Fellow at the Evans School of Public Affairs at the University of Washington. Her work focuses on global health workforce capacity and health systems, most recently relating to innovative investment/impact investment in the health sector as means for empowering women and strengthening health systems, focusing on nursing/midwifery enterprise. Dr. Salmon is former director of US Department of Health and Human Services’ Division of Nursing, chaired WHO’s Global Advisory Group for Nursing and Midwifery. She is a member of the Institute of Medicine and the American Academy of Nursing. She holds a doctorate from the Johns Hopkins School of Hygiene and Public Health, and degrees in nursing and political science.

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References

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Picazo, O., Ulep, V. G. T., Pantig, I., Ortiz, D., Aldeon, M., & de la Cruz, N. A. (2014). Innovations in the provision of health services using empowered nurses and midwives in the Philippines. Retrieved from http://www.nap.edu/read/19005/chapter/17 PRINMAT Tanzania. (2015). PRINMAT: Private Nurses Midwives Assocation. Retrieved from http://www.prinmat.org/membership-support.html Sable, S. (2015, June 11). Opportunities await the private sector in East Africa. International Partnership for Innovative Healthcare Delivery (IPIHD). Salmon, M., Maeda, A. (2015). Investing in nursing and midwifery enterprise to empower women and strengthen health services and systems: an emerging global body of work.Nursing Outlook. DOI: http://dx.doi.org/10.1016/j.outlook.2015.11.010; in press, published online, November 22,2015. Schultz, T. P. (2010). Health Human Capital and Economic Development. Journal of African Economies, 19(Supplement 3), iii12–iii80. doi:10.1093/jae/ejq015 Sibley, L., Sipe, T. A., & Koblinsky, M. (2004a). Does traditional birth attendant training improve referral of women with obstetric complications: A review of the evidence. Social Science Medicine, 59(8), 1757-1768. doi: 10.1016/j.socscimed.2004.02.009 Sibley, L. M., Sipe, T. A., & Koblinsky, M. (2004b). Does traditional birth attendant training increase use of antenatal care? A review of the evidence. Journal of Midwifery & Wome n's Health, 49(4), 298-305. doi: 10.1016/j.jmwh.2004.03.009 Spilerman, S. (2008). How Globalization Has Impacted Labour: A Review Essay. European Sociological Review, 25(1), 73–86. doi:10.1093/esr/jcn056 Time. (2014). The nurses: The Ebola fighters in their own words. Retrieved from http://time.com/time-person-of-the-year-ebola-nurses/ United Nations Development Programme. (2014). Gender equality strategy 2014-2017. Retrieved from http://www.tn.undp.org/content/undp/en/home/librarypage/womens-empowerment/gender-equality-strategy-2014-2017.html United Nations Global Compact. (2015). Women’s empowerment principles. Retrieved from http://weprinciples.org/Site/PrincipleOverview/ Usher, K., Park, T., Trueman, S., Redman-Maclaren, M., Casella, E., & Woods, C. (2014). An educational program for mental health nurses and community health workers from Pacific Island countries: Results from a pilot study. Issues in Mental Health Nursing, 35(5), 337-343. doi: 10.3109/01612840.2013.868963 Viterna, J., Fallon, K. M., & Beckfield, J. (2008). How Development Matters: A Research Note on the Relationship between Development, Democracy and Women’s Political Representation. International Journal of Comparative Sociology, 49(6), 455–477. doi:10.1177/0020715208097789 von Roenne, A., von Roenne, F., Kollie, S., Swaray, Y., Sondorp, E., & Borchert, M. (2010). Reproductive health services for refugees by refugees: An example from Guinea. Disasters, 34(1), 16-29. doi: 10.1111/j.1467-7717.2009.01112.x

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ICN Policy Brief ICN Policy Brief

The contribution of nursing to the development of a country level plan for meeting the WHO Global Strategy on Human Resources for Health:

Workforce 2030 requirements Author Prof Jill White, AM RN RM MEd PhD

Purpose The purpose of the paper is to provide a background for briefings with health officials on the contribution of nursing to the development of a country level plan for meeting the World Health Organization (WHO) Global Strategy on Human Resources for Health (HRH): Workforce 2030 requirements. The current global health agenda and the process for decision making are at a most critical time for future direction setting and all member states of the WHO are being called upon to commit to targets and strategies to ensure a sufficient, appropriately prepared workforce to meet the country’s health needs. This paper should be read in relation to the zero draft of the “WHO Global Strategy on Human Resources for Health: Workforce 2030”. Background The Millennium Development Goals (MDGs) with the end-point of 2015 have been a powerful force in maintaining political support for health development because of the clarity of the objectives and measurable targets. The post-2015 development agenda has been driven by the United Nations (UN) High-level Panel of Eminent Persons. This High-level Panel received a report from a UN System Task Team, which set out a broad framework for post- 2015, with four pillars: inclusive economic development; environmental sustainability; inclusive social development, including health; and peace and security, underpinned by human rights, equality and sustainability.1 Ultimately, this work led to the development and formal endorsement, at a UN meeting on 25 September 2015, of the Sustainable Development Goals (SDGs).2 There is no doubt that the SDG agenda will provide the investment framework for the next 15 years. The SDG agenda addresses many of the “unfinished business” of the MDGs and takes the new health landscape into account. While keeping the health MDG targets, the growing challenge of non-communicable diseases (NCDs) and their risk factors have also been included, with clear targets and indicators being developed.3 With the formal approval of the SDG goals and targets, the WHO Global Strategy on Human Resources for Health: Workforce 2030 will provide concrete recommendations and ideas on how to achieve these targets at a more technical level.

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The role of nursing in the HRH strategy is of utmost importance as the more than 16 million nurses practicing worldwide form the backbone of healthcare provision in almost every country. Country Ministries of Health are the WHA Member States and have the opportunity to comment at the WHO Executive Board (EB) meeting in January 2016 (if they are currently members of the EB), and the World Health Assembly (WHA) in May 2016 when the HRH Global Strategy will be brought for final endorsement. Inclusion of the insights from nursing, representing the major health professional body in the country, in the planning and decision-making process could assist greatly in the development of national targets and indicators that are achievable and realistic. Sustainable Development Goals (SDGs) For 15 years, the MDGs became the focus of the funding priorities for work with developing countries and the targets against which progress in world health was largely measured. They quickly became a major global focus and spawned some very influential and now very large healthcare organisations such as GAVI (immunisations), the Global Fund and UNAIDS (HIV/AIDS and other infectious diseases); and increased prominence for organisations such as UNFPA (maternal health). The next 15 year strategy for the UN is embodied in the SDGs and is well underway, having commenced in Rio in 2012 and been formally adopted by the United Nations (UN) in 2015.2 The goals and targets will be followed up and reviewed using a set of global indicators. These will be complemented by indicators at the regional and national levels which will be developed by member states, in addition to the outcomes of work undertaken for the development of the baselines for those targets where national and global baseline data does not yet exist. The global indicator framework, to be developed by the Inter Agency and Expert Group on SDG Indicators, will be agreed by the UN Statistical Commission by March 2016 and adopted thereafter by the Economic and Social Council and the General Assembly, in line with existing mandates. This framework will be simple yet robust, address all SDGs and targets including for means of implementation, and preserve the political balance, integration and ambition contained therein. If the indicators chosen are not sensitive to the work of the largest sector of the health workforce many of the health outcomes (positive or negative) for the country risk invisibility for the 15 years span, 2016-2030. The Official Agenda for Sustainable Development adopted on 25 September 20152 has 92 paragraphs, with the main paragraph (51) outlining the 17 Sustainable Development Goals (Appendix 1) as follows:

1. End poverty in all its forms everywhere 2. End hunger, achieve food security and improved nutrition and promote sustainable

agriculture[ 3. Ensure healthy lives and promote well-being for all at all ages 4. Ensure inclusive and equitable quality education and promote lifelong learning

opportunities for all 5. Achieve gender equality and empower all women and girls 6. Ensure availability and sustainable management of water and sanitation for all 7. Ensure access to affordable, reliable, sustainable and modern energy for al 8. Promote sustained, inclusive and sustainable economic growth, full and productive

employment and decent work for all

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9. Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation

10. Reduce inequality within and among countries 11. Make cities and human settlements inclusive, safe, resilient and sustainable 12. Ensure sustainable consumption and production patterns 13. Take urgent action to combat climate change and its impacts 14. Conserve and sustainably use the oceans, seas and marine resources for

sustainable development 15. Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably

manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss

16. Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels

17. Strengthen the means of implementation and revitalize the global partnership for sustainable development

As noted above, there is one health related goal: Goal 3 “Good Health and Well-being: ensure heathy lives and promote well-being at all ages”, and this has nine sub-goals or targets (See Appendix II). However, as seen above, many of the others SDGs relate to health, not the least being Goal 6 “clean water and sanitation” which is inherently also linked to Goal 13 “climate action”, particularly for Island and Delta countries. This underlines the intent of the SDGs which is that they are deliberately “integrated and indivisible and balance the three dimensions of sustainable development”: economic, social and environmental.2. Other SDG targets that directly impact health

• Eliminate all forms of violence against all women and girls in the public and private spheres, including trafficking and sexual and other types of exploitation

• Significantly reduce all forms of violence and related death rates everywhere • End abuse, exploitation, trafficking and all forms of violence against and torture of

children • By 2030, end hunger and ensure access by all people, in particular the poor and

people in vulnerable situations, including infants, to safe, nutritious and sufficient food all year round

• By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons

• By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations

The infrastructure is well is in place to tackle the first three goals as they were carried over from the MDGs. However, major current health related issues such as NCDs, substance abuse, traffic accidents and injuries, sexual and reproductive health services, disaster relief, affordable, accessible models of care, and environmental safety are all areas in which nurses can and do play a major role and it is important the nursing impact is accounted for explicitly in the indictors for each of these areas. Each country is to develop its own exact accountable target so the opportunity for local influence exists and nurses are most keen to be part of the solution.

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As of August 2015, there were 169 proposed targets for these goals and 304 proposed indicators to show compliance.3 For further information on the SDGs, click on this link: http://kff.org/global-health-policy/event/web-briefing-for-media-what-do-the-sustainable-development-goals-mean-for-global-health/. It is a one hour briefing for journalists on the SDGs. WHO Global Strategy on Human Resources for Health: Workforce 20304 The Global Strategy was developed in response to a resolution passed at the 2014 World Health Assembly (WHA) which recognised the development of the SDGs and the importance of a global HRH strategy to support this work. The draft strategy builds upon global evidence and experience, as well as broad-based consultation in the period 2013-2015 with experts at the global, regional and national level, and has been informed by thematic papers, related global guidelines, policy commitments, regional strategies and initiatives. As noted, the document starts with a “Vision” statement of the Global Strategy on HRH which states that it seeks to: “Accelerate progress towards Universal Health Coverage and the Sustainable Development Goals by ensuring equitable access to skilled and motivated health worker within a performing health system.”4 The supporting overall goal further elaborates this statement by identifying that, “ensure(ing) availability, accessibility, acceptability and quality of the health workforce through adequate investments and the implementation of effective policies at national, regional and global levels, for ensuring healthy lives for all at all ages, and promoting equitable socio-economic development through decent employment opportunities.” This section is followed by a series of supporting principle statements. Equitable access, skilled and motivated health workers, and a performing health system are easily understood as essential building blocks for achieving improved health outcomes, despite the difficulties in achieving these. As well it is important to reflect upon the meaning and significance of the words “Universal Health Coverage” and “Sustainable Development Goals”. The next sections of the Global HRH Strategy identify four objectives with targets and supporting policies. Reading this section of the Global Strategy document carefully, it is important to consider how this relates at country level. The objectives are: “1. To implement evidence-based HRH policies to optimize impact of the current health

workforce, ensuring healthy lives, effective Universal Health Coverage, and contributing to global health security.

2. To align HRH investment decisions at national and global levels to current and future needs of the health systems and demand of the health labour market, maximizing opportunities for employment creation and economic growth.

3. To build capacity of national and international institutions for an effective leadership and governance of HRH actions.

4. To ensure that reliable and up-to-date HRH data, evidence and knowledge underpin monitoring and accountability of HRH efforts at national and global levels.” 4

The Strategy ends with two sections that identify the roles for both the WHO Director General and NGO and other stakeholders to support the work. Nurses and nursing organisations are ready and willing to collaborate in this work. There is a significant body of

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evidence of the relationship of nursing educational levels, nursing staffing and workplace environment to the health outcomes for people. Issues and policies such as access to care, quality of care, patient safety, safe working environments, and healthcare financing would all be enhanced with nursing input. Steps in Formal Adoption of WHO Global Strategy on HRH: Workforce 2030 The consultation process by WHO on the Global Strategy has followed their normal governance process: online public consultations were held in July-August 2015; Member States consultation at WHO Regional Committee meetings in Sept-Nov 2015; EB discussion in January 2016; and WHA formal adoption in May 2016. The first two steps in this process have been completed. ICN and national nursing associations (NNA) have contributed to these processes and their submissions are available. WHO staff are currently redrafting the document based upon these consultations. A revised version of the Global Strategy for HRH: Workforce 2030 will be discussed by the WHO EB at its January 2016 meeting and considered at the WHA in May 2016. The WHO under the current Director General, Dr Margaret Chan, has become very focused on evidence-based policy. Being abreast of the evidence in relation to human resources for health and its impact on patient and population outcomes enables NNA to assist governments in meeting targets through nursing and the essential contribution of nursing to the global HRH strategy succeeding and to achieving the SDGs for our collective sustainable development. About ICN The International Council of Nurses (ICN) is a federation of more than 130 national nurses associations representing the millions of nurses worldwide. Operated by nurses and leading nursing internationally, ICN works to ensure quality nursing care for all and sound health policies globally.

About the Author Professor Jill White, Dean Emerita, Professor of Nursing and Midwifery, Faculty of Nursing and Midwifery, University of Sydney, Australia; Senior Fulbright Scholar 2015, School of Nursing, University of Pennsylvania; Senior Scholar in Residence ICN, May-June 2015, Geneva. Professor White has extensive international experience, most recently in Tonga and Vietnam. She was the founder of the UTS WHO Collaborating Centre and facilitated the formation of the South Pacific Chief Nursing and Midwifery Officers Alliance.

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References

1. World Health Organization (2013). World Health Report. Research for Universal Health Coverage. Retrieved from: http://apps.who.int/iris/bitstream/10665/85761/2/9789240690837_eng.pdf

2. United Nations General Assembly (2015) Transforming our world: the 2030 agenda for sustainable development. A/70/L.1, 18 September.

3. World Health Organization (2012). Health Indicators for Sustainable Development Goals. Geneva: WHO. Retrieved from: www.who.int/hia/health_indicators/en/.

4. Global Health Workforce Alliance & WHO (2015) Health Workforce 2030 Towards a global strategy on human resources for health: a synthesis paper of the thematic working groups. Geneva: GHWA/WHO.

5. World Health Organization (2014). Global Coalition Calls for Acceleration of UHC. Geneva: WHO. December 12. Retrieved at: www.who.int/universal_health_coverage/en

6. ICN/World Bank (2014) Strengthening Community and Frontline Health Workers for universal Health Coverage: Event Summary. July. Geneva. Retrieved at: www.nurse.or.jp/nursing/international/icn/report/pdf/2014m/08-06.pdf.

7. Institute of Medicine (2011) The Future of Nursing: leading change, advancing health. Washington, DC: The National Academic Press.

8. ICN (2015) Nursing a Force for Change: Care effective, cost effective. Geneva: ICN. 9. World Health Organization (2003) Investing in Health: a summary of the findings of the

Commission on Macroeconomics and Health. Geneva: WHO CMH Support Unit. 10. World Health Organization (2011) Strategic Directions for Strengthening Nursing and

Midwifery Services 2011-2015. Geneva: WHO.

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APPENDIX I SUSTAINABLE DEVELOPMENT GOALS:

http://www.un.org/sustainabledevelopment/sustainable-development-goals/

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APPENDIX II Goal 3. Targets. Ensure healthy lives and promote well-being for all at all ages 3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live

births 3.2 By 2030, end preventable deaths of newborns and children under 5 years of age,

with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under 5 mortality to at least as low as 25 per 1,000 live births

3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases

3.4 By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being

3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol

3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents 3.7 By 2030, ensure universal access to sexual and reproductive healthcare services,

including for family planning, information and education, and the integration of reproductive health into national strategies and programmes

3.8 Achieve universal health coverage, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all

3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination

3a Strengthen the implementation of the World Health Organization Framework

Convention on Tobacco Control in all countries, as appropriate 3b Support the research and development of vaccines and medicines for the

communicable and non-communicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all

3c Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States

3d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks http://www.un.org/ga/search/view_doc.asp?symbol=A/70/L.1&Lang=E

UN General Assembly, 18 September 2015.