What the Covid-19 Pandemic has Exposed: The Findings of Five Global Health Workforce Professions

WHAT THE COVID-19
PANDEMIC HAS EXPOSED:
THE FINDINGS OF FIVE
GLOBAL HEALTH WORKFORCE
PROFESSIONS
Human Resources for Health Observer Series No. 28
Erin Downey, Hoi Shan Fokeladeh and Howard Catton
WHAT THE COVID-19
PANDEMIC HAS EXPOSED:
THE FINDINGS OF FIVE
GLOBAL HEALTH WORKFORCE
PROFESSIONS
Human Resources for Health Observer Series No. 28
Erin Downey, Hoi Shan Fokeladeh and Howard Catton
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions/ Erin Downey, Hoi Shan Fokeladeh, Howard Catton
(Human Resources for Health Observer Series No. 28)
ISBN 978-92-4-007018-9 (electronic version)
ISBN 978-92-4-007019-6 (print version)
©World Health Organization 2023
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iii
Contents
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv
Acronyms and abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Executive summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
Purpose and target audience. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Background
.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
WHPA global representation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
A conceptual framework to measure the multidimensional impact of the COVID-19 pandemic on HCWs. . . . . . . 5
Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
WHPA surveys and reports. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Data quality assessment and analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Results and key findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Theme 1: Occupational and/or psychosocial factors affecting HCWs’ morbidity and mortality levels: mainly
related to infections, death, extreme stress (post-traumatic) and suicide, increased accidents at work,
burnout and other mental health conditions
.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Theme 2: HCWs’ temporary or permanent departures from service: mainly due to multiple factors (such
as, unmanageable workload, long COVID, fears of excess morbidity and mortality given the unpredictable
period of the outbreak or emergency situation, among others), and/ or other external factors (e.g. social and
environmental)
.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Theme 3: HCWs’ access to and uptake of COVID-19 vaccinations: mainly knowledge around vaccination
coverage among HCWs; and the main enablers and barriers to rapidly achieving high coverage of COVID-19
immunization of HCWs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Theme 4: Common causes and key manifestations of industrial actions, protests, strikes and lockouts
(IAPSLs): mainly related to the general welfare of HCWs (fair pay, workload, safety, security). . . . . . . . . . . . . . 17
Theme 5: Detrimental consequences of any of themes 1-4 above, mainly evidence related to the delivery and
quality of health services i.e., prolonged service disruptions, interruptions in HCW education. . . . . . . . . . . . . . 19
Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Conclusion
.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Annex 1: A compilation of WHPA organizations’ survey questions. . . . . . . . . . . . . . . . . . . . . . . . 34
Annex 2: Countries, territories and areas not included in WHPA-WHO-MS
representation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Annex 3: Lessons learnt and best practices published by members of WHPA. . . . . . . . . . . . . 45
References
.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
iv
Acknowledgements
The lead author of this report is Erin Downey, Visiting Scientist at Harvard Humanitarian Initiative, who also compiled
reports, policy briefs and surveys published by members of the World Health Professions Alliance (WHPA) for the
content referred to in the report. Additional authors are Hoi Shan Fokeladeh, Policy Advisor at the International Council
of Nurses (ICN), and Howard Catton, Chief Executive Officer at ICN.
The authors would like to thank the collaborative support and contribution of the WHPA which was formed in 1999
and brings together the global organizations representing the world’s dentists, nurses, pharmacists, physicians and
physiotherapists. The member organizations in WHPA have demonstrated leadership and have made extensive efforts
in data collection related to the health and well-being of health and care workers in the most challenging times of the
COVID-19 pandemic. Special thanks go to each member organization in the WHPA – FDI World Dental Federation (FDI),
International Pharmaceutical Federation (FIP), International Council of Nurses (ICN), World Physiotherapy, and World
Medical Association (WMA) – for providing valuable feedback and guidance during the report writing phase and the
transparent sharing of the data collected during the pandemic. The data provided by the organizations were central to
the development of this report.
The authors would especially like to thank Amani Siyam, Tapas Sadasivan Nair, Khassoum Diallo and James Campbell
from the WHO Health Workforce Department for their technical inputs and continued support during the process of
developing and finalizing this report.
Publisher’s note:
This publication is aligned with and has been developed under the framework for joint action outlined in the
Memorandum of Understanding (MoU) signed by the World Health Organization (WHO) with the five members of
the World Health Professions Alliance (WHPA) – FDI World Dental Federation (FDI), International Pharmaceutical
Federation (FIP), International Council of Nurses (ICN), World Physiotherapy, and World Medical Association
(WMA) – on 8 November 2022.
This report is being published as an issue of the HRH Observer series as it presents a synthesis of evidence
from the five WHPA organizations’ surveys and reports during the COVID-19 pandemic using the standardized
measurement and reporting framework developed by WHO to assess the multidimensional impact of COVID-19 on
the health and care workers. While the framework has been utilized by WHO and by other partners and Regions,
this is the first assessment of its kind which focuses on the perspectives of the professional associations of health
workers, and hence this report can provide useful insights to inform policy responses and priorities to protect,
safeguard and invest in the health and care workforce.
v
Acronyms and abbreviations
APN advanced practice nurse
CDC Centers for Disease Control and Prevention (United States of America)
FDI FDI World Dental Federation
FIP International Pharmaceutical Federation
HCW health and care worker
HCWF health and care workforce
HRH human resources for health
IAPSL industrial actions, protests, strikes and lockouts
ICN International Council of Nurses
ICRC International Committee of the Red Cross
ILO International Labour Organization
IPC infection prevention and control
IYHCW International Year of the Health and Care Workers
MHPSS mental health and psychosocial support
MS Member State
MoU memorandum of understanding
NDA national dental association
NNA national nursing association
PHC primary health care
PHN public health nurse
PPE personal protective equipment
SDG Sustainable Development Goal
WHA World Health Assembly
WHO World Health Organization
WHPA World Health Professions Alliance
WMA World Medical Association
vi
Executive summary
As part of the International Year of the Health and Care Workers (IYHCW) 2021 Campaign activities, the World Health
Professions Alliance (WHPA) expressed interest in conducting a synthesis of the evidence and knowledge gathered
by its five organizations of the two-year impact of COVID-19 on health and care workers (HCWs) globally. The WHPA
includes the global organizations representing the world’s dentists, nurses, pharmacists, physicians and physiotherapists
and speaks for more than 41 million health care professionals in more than 130 countries. Thus, the WHPA can play a
key role in providing new insights into the impact of the COVID-19 pandemic as witnessed and responded to by their
members globally.
Early in the COVID-19 pandemic, WHO asserted that a holistic assessment of the COVID-19 pandemic’s impact is needed
and accordingly formulated a comprehensive framework for measurement and reporting that broadly draws upon four
main domains. Two domains, ‘health’ and ‘social and well-being,’ are central to the individual HCW and two domains,
‘availability and distribution’ and ‘working conditions,’ are central to the organizational and working environment. The
overarching goal of this holistic framework is to empower countries, global partners and WHO to collectively inform
strategies that guide recovery plans, future investments, and further develop the health and care workforce (HCWF) at
the national and global levels.
Relative to that, the primary objective of the evidence synthesis (guided by WHO’s four domains of interest) is to
triangulate data and information generated by the WHPA. It was conducted using information and report summaries
from WHPA to generate a comparative secondary analysis of the surveys conducted in the period 2020–2021. No
standardized data collection instrument, variable, or question was used across the five organizations. Instead, the
organizations gathered data from their respective national professional associations using various instruments and
developed reports that discussed either the pandemic specifically or in conjunction with additional priority issues. At
least one WHPA organization is represented in 169 (87%) of the 194 WHO Member States (MS). In 42 MS (21%), all
five WHPA organizations are represented.
This evidence synthesis describes how the five professions were impacted in common and different ways by comparing
the experiences of dentists, nurses, pharmacists, physicians and physiotherapists. The individual organizational findings
of the five WHPA organizations inform the five key themes and the subsequent findings and recommendations. The
inspiration was to inform future data collection efforts by building upon collective knowledge, data accessibility and
question formats that have generalizable applicability to all WHPA organizations.
All WHPA organizations brought a valuable perspective given the comprehensiveness of survey reporting, geographic
reach and analysis. For example, ICN had a strong grasp of how interruptions to nursing education will affect the
immediate and long-term impacts of workforce shortages. FDI assessed facility ownership (public/private sector) when
they assessed the impact of the pandemic on oral health care. World Physiotherapy collected the gender of its survey
participants among its physiotherapist members. FIP had an established and comprehensive multi-year data collection
process for pharmacists. WMA has a streamlined policy generation process that creates statements, declarations and
resolutions for physicians and the medical community.
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Human Resources for Health Observer Series No. 28
This evidence synthesis aims to influence the dialogue between policy-makers, non-governmental organizations and
public health research stakeholders on diverse priorities related to the support, protection and investment of HCWs
during the COVID-19 response and beyond by presenting key findings, messages and calls for action related to HCW
protection and future investments. This report intends to expand the understanding of the occupational risks and pervasive
workload challenges, highlight the consequences to the HCWF, and explore the need to standardize the monitoring of the
HCWs’ context during public health emergencies. In conjunction with the WHPA organizational review, the WHO HWF
department reviewed this document during its development to ensure alignment with the standardized framework to
assess the multidimensional impact of COVID-19 on HCWs and coherence with the relevant WHO documents and policies.
Key findings
Investing in and ensuring access to mental health and psychosocial support (MHPSS) services for HCWs globally
is paramount. This includes both individual interventions to support those in need of care, as well as organizational
interventions that reduce risk factors, for example the improvement of working conditions, protecting and safeguarding
the rights of workers, identifying and reducing barriers to accessing support. HCWs have long been a population at risk of
mental health problems due to high-stress environments and poor working conditions. During the COVID-19 pandemic,
this risk increased, with personal safety being one of many risk factors for poor mental health in this population. Fears for
personal safety included lack of occupational protection via personal protective equipment (PPE) and rapidly changing
and inconsistent protocols that undermined their feelings of personal safety and could affect patient care.
HCWs interpret the lack of systematic protection mechanisms for their safety and security as being undervalued.
Workload burden, resulting in temporary and permanent departures from service, was extensively reported by nurses
as reasons for depressive symptoms, anxiety, fear, inequality and discrimination at the workplace.
The need for HCW representation at high levels of planning, strategy, and decision-making was reported by almost all
organizations. The reliance that communities have on HCWs and the reliance that HCWs have on the whole of society
to perform their roles must be integrated into immediate and long-term strategies.
Vaccination communication strategies should be dual-purpose, both for this pandemic and other pervasive and long-
standing vaccination challenges. ICN found that an enabler for vaccine coverage was to utilise the presence of nurses
through public information channels that strengthen their community integrity and value, including assisting with
distributing vaccine recommendations that can “create a better understanding of health and healthcare through the
nursing voice.”
Providing vaccinations training for HCWs was extensively discussed by FDI (representing dentists) as a primary effort
to achieve better coverage across populations when their services had otherwise decreased due to the pandemic.
Guidelines and recommendations for HCWs testing for COVID-19 are available in most countries, however, routine testing
of the HCWF is not implemented. FDI and FIP also noted their relevance in community education for their respective
professions of oral and pharmacy care.
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
viii
ICN reported that more than 70% (n=24) of the national nursing associations (NNAs) experienced incidents of violence
or discrimination against essential health workers due to COVID-19.
FIP extensively covers vaccination and provides multiple strategies, recommendations and examples in its toolkit
that aims to support individual pharmacists with tools for effectively communicating the value, efficacy and safety of
vaccines, and for addressing concerns about or the rejection of vaccines. It provides a background on vaccine hesitancy
and the main reasons for it as well as ways to address vaccine hesitancy directly with individuals. It also includes examples
of pharmacy-based campaigns and information, and guidance on advice for different types of vaccines is also provided.
Interruptions of HCW education were profound. ICN extensively reported the impact of the pandemic on nursing students
and their education. Disruptions of undergraduate and postgraduate nursing education were reported in 68% and 56%
of countries respectively (n=64). Schools were closed, clinical placements were cancelled or postponed, and some
countries are experiencing delays of up to a year.
Societal inequalities across and within countries have been exacerbated during the pandemic and compounded the
impact on HCWs in ways of professional uncertainty, fatigue, fear, and temporary or permanent departures from service.
Overarching findings and conclusions from the review
Future surveying of HCWs should include a combined prioritization of the issues discussed herein that anticipate the
context of recovery and health systems strengthening through education, advocacy and policy. Suggested topic areas
are described in Box 1 but could evolve as per WHPA and WHO priority areas. Future data collection should engage
individual reporting expertise from all WHPA organizations.
Box 1. Key areas of consideration for future surveys
Key demographics and socio-economics
Impact of the COVID-19 pandemic (infections, deaths)
Impact on mental health
Impact on professional practices
Testing and vaccination coverage
Repurposing and redistribution
Public image of the profession
Government and regional level support
Coordination support
Communication campaigns and advocacy
Registration and regulation
Reasons for leaving the profession
Education and training
Financial implications
Future of the profession
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Human Resources for Health Observer Series No. 28
The consequences of service disruptions need further exploration, including the immediate and long-term impacts
on HCWs. Issues of ‘repurposing’ HCWs to perform other duties may incentivize some to stay within the profession or
deter others to leave. Student HCWs as a potential resource for backfilling some service gaps would likely welcome the
opportunity to assist in some ways but naturally have limitations in how and what services they can perform. The 2030
pre-pandemic projected shortfall of 18 million health care workers in general and the 10 million nurses specifically have
been exacerbated by the COVID-19 pandemic. Strategies to mitigate this shortage are urgently needed. The relationship
between service disruptions and the subsequent impact on the temporary or permanent loss of staff is complex.
Retraining staff for ‘repurposing’ in the context of a global public health emergency is a compelling strategy and requires
more extensive and thorough implementation strategies. To address mis- and dis-information campaigns, extensive
references are made herein on strategies, such as those used by FIP within the pharmaceutical profession.
Key messages
The COVID-19 pandemic has brought to the fore the urgent need to protect and safeguard HCWs. The COVID-19 pandemic
has made clear that the obligations implicit in duty of care extend to the systems which support those personnel.
Simultaneously, the need for, and the reliance on, a strong HCWF has been recognized. The HCW is a key mechanism
that operationalizes global health policies while ensuring access to health, as a fundamental right, occurs. They must
be globally respected and protected.
Deliberate and immediate engagement with HCWs at the national planning, policy and finance levels should occur.
Without adequate representation, HCWs will continue to bear a disproportionate responsibility to recover from health
emergencies; they will remain in the position of having the responsibility to implement solutions without having the
authority to do so.
Systemic strategies to concretely address the chronic violence in the health care settings should be curated and
invested in. The exposure to violence, safety and protection concerns and the subsequent mental health and psychosocial
impacts on HCWs is multifaceted. Chronic violence that occurs during non-emergency settings exacerbates during
emergency situations. Fragmented data collection, fragmented coalitions, and fragmented operational efforts are not
enough. Comprehensive HCW protection strategies implemented at the national and local levels are essential. To do so
would be a force multiplier in addressing the MHPSS realities of the HCW and the subsequent loss of temporary and
permanent departures from service.
The compounding risks to HCWs must be immediately mitigated through (a) proactive not reactive policies; (b) strategies
to address secondary and tertiary impacts of fears and fatigue; and (c) resources made available for short- and long-
term effects of mental and psychosocial impacts. HCWs are the fundamental resource that bridges health systems
from response to recovery to deliver the essential health services and the essential public health functions in pursuit of
UHC and global health security.
Data and intelligence needs should be anticipated and strategic planning for emergency risk communication should be
integrated in preparedness strategies for health emergencies. Globally, social media has never been more pervasive.
With constant flows of information that range in quality and content, the pressure to manage public messaging during
health emergency contexts is extreme.
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
x
Immunization campaigns should be coordinated. In most countries, health workers are not typically included as a target
population group for the national immunization programme. It is necessary therefore to include measurable and realistic
immunization targets based on the national immunization plans and gaps in vaccine coverage. Target percentages set
by federal governments for immunization rates can serve as a baseline for pharmacy-led campaigns.
The importance of equity stratifiers such as gender, age, level of education, ethnicity, place of birth and/or place of
training, civil status and sector of employment to describe the lived experiences of HCWs cannot be understated. For
disaggregation by equity stratifiers to become an integral part of policy-making, there needs to be a firm evidence base.
This evidence synthesis showed a limited attention to this aspect. Moving forward, this gap will need to be filled.
Enablers and barriers to rapidly achieving high coverage of COVID-19 immunization of HCWs reflect the need to
engage anthropologists on a much deeper level. Information and media forces during this unprecedented public
health emergency were not anticipated. Lessons learnt from the pandemic are opportunities for prioritizing the issues
to address while complementing them with short- and long-term visions of how recovery can strengthen the delivery of
essential health services and the essential public health functions, UHC, global health security and future preparedness.
This evidence synthesis is the first of its kind to assess the multidimensional impact of COVID-19 on five major HCW
occupations globally. It demonstrates the important role that WHPA can play by contributing to investigate, represent,
and create linkages between health systems strengthening and response priorities within the health sector to contribute
to the operationalization of HCW protection. The COVID-19 pandemic relentlessly underscored the inequities of access to
health as well as how HCWs are disproportionately at-risk during health emergencies. Given the projected HCW shortfall
for 2030, WHPA could serve as a health intelligence body that informs global strategy and policy.
1
As part of the International Year of the Health and Care
Workers (IYHCW) 2021 Campaign activities, the World
Health Professions Alliance (WHPA) expressed interest
in conducting a synthesis of the evidence and knowledge
gathered by its five organizations on the two-year impact
of COVID-19 on health and care workers (HCWs) globally.
The WHPA includes the global organizations representing
the world’s dentists, nurses, pharmacists, physicians and
physiotherapists and speaks for more than 41 million
health care professionals in more than 130 countries (1).
The WHPA recently signed a historic memorandum of
understanding (MoU) with WHO to enhance their joint
collaboration on protecting and investing in the health
workforce to provide safe, quality and equitable care
in all settings. The MoU provides a framework for joint
action between the five organizations and WHO on various
priority health workforce issues. Thus, the WHPA can play
an important role in gleaning new insights into the impact
of the COVID-19 pandemic as witnessed and responded
to by their members globally. This report synthesizes
the evidence from the WHPA data sources and summary
reports contributed by their stakeholders to facilitate a
descriptive analysis of findings and key messages.
Early in the COVID-19 pandemic, WHO asserted that
a holistic assessment of the impact is needed and
accordingly elaborated a comprehensive measurement
and reporting framework for the multidimensional impact
of COVID-19 on HCWs that broadly draws upon four main
domains (2). Two domains, ‘health’ and ‘social and well-
being,’ are central to the individual HCW and two domains,
‘availability and distribution’ and ‘working conditions,’ are
central to the organizational and working environment.
The overarching goal of this comprehensive framework
is to empower countries, global partners, and WHO to
collectively inform strategies that guide recovery plans,
future investments, and further develop the health and
care workforce (HCWF) at the national and global levels.
Purpose and target audience
The purpose of this report is to act as an advocacy
document to global, regional and national leaders and
decision-makers working in the health systems and
health workforce domains, sensitizing them about the
multidimensional impact of COVID-19 on HCWs, the
need to think beyond just infections and deaths, and the
importance of investing, protecting and safeguarding this
workforce. Hence, addressing the impact of COVID-19
on HCWs should be comprehensive and focus on all the
four domains, ensuring not just the health and social
well-being of the HCWs, but also their availability and
distribution and working conditions. Secondly, it also aims
to draw the attention of human resources for health (HRH)
planners, policy-makers, program managers, researchers
and analysts to the standardized framework developed
by WHO to measure and report on the multidimensional
impact of COVID-19 on HCWs, and to motivate them to
apply the framework to measure impact at national level.
Objectives
The primary objective of the evidence synthesis was to
triangulate data and information gathered by the WHPA,
guided by WHO’s four domains of interest. Five broad
research themes were identified, which are outlined as
follows:
Theme 1: Occupational and/or psychosocial factors
affecting HCWs’ morbidity and mortality levels: mainly
related to infections, death, extreme stress (post-
traumatic) and suicide, increased accidents at work,
burnout and other mental health conditions.
Background
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
2
Theme 2: HCWs’ temporary or permanent departures
from service: mainly due to multiple factors (such as,
unmanageable workload, long COVID, fears of excess
morbidity and mortality given the unpredictable period of
the outbreak or emergency situation, among others), and/
or other external factors (e.g. social and environmental).
Theme 3: HCWs’ access to and uptake of COVID-19
vaccinations: mainly knowledge around vaccination
coverage among HCWs; and the main enablers and
barriers to rapidly achieving high coverage of COVID-19
immunization of HCWs.
Theme 4: Common causes and key manifestations of
industrial actions, protests, strikes and lockouts (IAPSLs):
mainly related to the general welfare of HCWs (fair pay,
workload, safety, security).
Theme 5: Detrimental consequences of any of themes 1-4
above: mainly evidence related to the delivery and quality
of health services i.e., prolonged service disruptions,
interruptions in HCW education.
A secondary objective of this evidence synthesis is to
provide key messages on the underlying data gathering
processes and information sources that are needed
to underpin coherent calls for investments in the core
objectives of the IYHCW Campaign (Box 2).
WHPA global representation
The WHPA is comprised of five organizations:
FDI World Dental Federation (FDI)
(https://www.fdiworlddental.org/members)
International Council of Nurses (ICN)
(https://www.icn.ch/who-we-are/membership)
International Pharmaceutical Federation (FIP)
(https://www.fip.org/member-organisations)
World Medical Association (WMA)
(https://www.wma.net/who-we-are/members/)
World Physiotherapy
(https://world.physio/our-members)
Each of the five organizations have their member
associations posted in the public domain and membership
counts can fluctuate. At the time of this comparative
analysis, the organizations’ global presence across
countries, territories and areas ranged from 116 to 146
(average 130) member associations per organization
(seen later in Table 4). On average, each professional
organization had between 1 and 3 member associations
in any given country. Figure 1 depicts the global
CAMPAIGN OBJECTIVES
Ensure the world’s
health and care
workers are prioritised
for the COVID-19
vaccine in the first
100 days of 2021.
Recognize and
commemorate all
health and care
workers who have
lost their lives during
the pandemic.
Mobilize commitments
from Member States,
International Financing
Institutions, bilateral and
philanthropic partners to
protect and invest in
health and care workers
to accelerate the
attainment of the SDGs
and COVID-19 recovery.
Engage Member
States and all relevant
stakeholders in
dialogue on a care
compact to protect
health and care
workers’ rights, decent
work and practice
environments.
Bring together
communities,
influencers, political
and social support in
solidarity, advocacy
and care for health
and care workers.
Box 2. Objectives of the campaign to support the International Year of Health and Care Workers
3
Human Resources for Health Observer Series No. 28
representation of WHPA in countries (those darkest in
colour have all 5 professions represented and vice versa).
Overall, at least one of the five WHPA professions has
representation in 180 countries, territories and areas
globally. Specifically, at least one WHPA organization
has representation in 169 (87%) of WHO 194 Member
States (MS) (Table 1), and all five WHPA organizations
are represented in 42 (21%) WHO MS (Table 2), which
are distributed across all but one WHO region (the Eastern
Mediterranean region). Further details of the available data
for non-WHO MS with and without WHPA representation
are provided in Annex 2.
Figure 1: WHPA global representation
M em bers cou n t
1
5
N o data
N ot applicable
Data Sou rce: World H ealth Profession s
Allian ce, Ju n e 2022
Th e design ation s em ployed an d th e presen tation of th e m aterial in th is pu blication do n ot im ply th e expression of
an y opin ion wh atsoever on th e part of WH O con cern in g th e legal statu s of an y cou n try, territory, city or area or of
its au th orities, or con cern in g th e delim itation of its fron tiers or bou n daries. Dotted an d dash ed lin es on m aps
represen t approxim ate border lin es for wh ich th ere m ay n ot yet be fu ll agreem en t.
World H ealth Profession s Allian ce (WH PA) organ ization s
M ap Creation Date: 21 June 2022
M ap Produ ction : WH O GI S Cen tre for H ealth , DN A/DDI
© WH O 2022. All righ ts reserved.
Table 1: Distribution of WHPA member organizations across WHO Member States
WHO Region No. of WHO
MS
No. of WHO MS where at least one of
the five professional organizations is
represented (%)
No. of WHO MS where all five
professional organizations are
represented (%)
Africa 47 42 (89%) 8 (17%)
The Americas 35 32 (91%) 5 (14%)
South-East Asia 11 10 (91%) 5 (45%)
Europe 53 50 (94%) 19 (36%)
Eastern Mediterranean 21 19 (90%) 0
Western Pacific 27 16 (59%) 5 (19%)
Total 194 169 (87%) 42 (22%)
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
4
Table 2: WHO Member States (n=42) where all five WHPA organizations are represented
Africa
(n=8)
The Americas
(n=5)
South-East Asia
(n=5)
Europe
(n=19)
Western Pacific
(n=5)
Ethiopia
Ghana
Kenya
Nigeria
Rwanda
Senegal
South Africa
Zimbabwe
Argentina
Chile
Costa Rica
Panama
Peru
Bangladesh
India
Indonesia
Nepal
Sri Lanka
Austria
Belgium
Bulgaria
Cyprus
Denmark
Germany
Greece
Iceland
Ireland
Italy
Luxembourg
Montenegro
Poland
Portugal
Romania
Spain
Sweden
Switzerland
United Kingdom
Australia
Japan
Malaysia
Philippines
Singapore
Note: The WHO Eastern Mediterranean Region has no Member States with all five WHPA organizations represented
5
A conceptual framework to
measure the multidimensional
impact of the COVID-19
pandemic on HCWs
During the first year of the pandemic, WHO elaborated
a conceptual framework to support the standardized
measurement and reporting of the multidimensional
impact of the pandemic on HCWs’ health and social well-
being, their working conditions and their availability and
distribution (Figure 2) based on emerging evidence (2,3).
Two domains, ‘health’ and ‘social and well-being’, are
centred more on the individual HCW while the two other
domains, ‘availability and distribution’ and ‘working
conditions’, are centred more on the organizational
and working environment. These four domains were
Methods
synthesized from various topics identified in the literature
and publications, and are also well-aligned with the health
labour market (HLM) framework (4) and the measurement
dimensions of the National Health Workforce Accounts
(NHWA) (5). The presented domains are not meant to
be mutually exclusive nor the factors within each to
be exhaustive. It is also evident that the interplay of
factors outlined in the four domains will vary from one
country to the other. For instance, HCWs may be impacted
more heavily by a specific domain (e.g. poor working
conditions) or a permutation of factors across the four
domains (Figure 2).
This framework has since been tested and validated in
various country case studies in South America (6), the
Caribbean (7) and Africa (8).
Figure 2: Multidimensional factors related to COVID-19 that affect HCWs
• Shortage and vacancies
• Repurposing
• Surge capacity
• SARS-CoV-2-related
absence
• Infections
• Deaths
• Stress
• Burnout
• Other mental health conditions
• Lack of personal protective
equipment
• Labour strikes
• Quarantine and self-isolation
• Temporary staff contracts
• Lack of incentives and insurance
• Violence and harassment
• Lack of psychological support
• Lack of COVID-19 vaccination
• Stigmatization and
discrimination
• Care for family members
AVAILABILITY
AND
DISTRIBUTION
WORKING
CONDITIONS
SOCIAL AND
WELL-BEING
HEALTH
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
6
WHPA surveys and reports
All WHPA organizations maintain active communications
with their member associations and this has increased,
particularly since the start of the COVID-19 pandemic in
early 2020. Given the scale, speed and severity of how
the pandemic unfolded, individual WHPA organizations
conducted multiple rounds of data collection at different
intervals to gain insights into how their respective
professions were being impacted, albeit that not all
organizations conducted pandemic-specific surveys. A
rapid review of literature related to the key priority issues
faced by the health occupation group was conducted by
the respective WHPA partner organization prior to the
development of their respective surveys.
Nine WHPA surveys and reports (shown in Table 3, below)
were central to this evidence synthesis. Unique qualities
for each of the WHPA organizations’ surveys and reports
revealed exclusive situational awareness, and specific
areas of concern at different points in time that were
explored in diverse ways. A few examples are outlined
as follows:
ICN extensively surveyed their national nursing
associations (NNAs) by conducting two surveys
(in August and December 2020): the initial
one focused on HCWs infections and deaths
during the pandemic and the second was more
comprehensive and included the impact of the
pandemic on the nursing workforce and the
development of the profession in general. As
such, three reports were contributed by ICN who
provided the most content on COVID-19 specific
impacts and most notably on the mental health and
psychosocial state of HCWs (9–11). Comparative
descriptive analysis of their data informed many
policy briefs and subsequent reporting.
FDI conducted two surveys of their national
dental associations (NDAs) – in May 2020, and
a follow-up in December 2020 – to probe on:
whether their oral health HCWs had access to
receive COVID-19 vaccination as a priority group,
whether they were retrained or repurposed as a
part of the vaccine-providing workforce, and a
deeper-dive into the type of facility ownership
(namely public or private sector) the oral health
workforce was involved with. In addition, FDI
also conducted a global survey for their Vision
2030 for oral health. (12–14).
FIP conducted a longitudinal analysis of the
pharmacist workforce data they held over 10 years
(15) that could inform the workforce capacity of
pharmacies as the pandemic evolved. Data was
primarily gathered using a survey of FIP member
organizations which included questions on the
number of practising pharmacists in the country.
Pharmacist capacity data collection occurred at
four successive time points (2006, 2009, 2012
and 2016), with 75 countries having contributed
data for at least two time points. In addition, FIP
conducted a follow-up global survey in 2020
to collect essential workforce data, including a
particular focus on the community pharmacy
workforce (16).
WMA conducted “COVID-19 talks” interviews
with more than 20 associations in the early
stages of the pandemic to inform the medical
community of foreboding health emergency
response challenges (17). As such, no survey
results exist for WMA but their members’
pandemic response policy developments are
extensively cited.
World Physiotherapy conducted a cross-
sectional survey (in June 2020) that included
questions on interruptions to service provision
(18). Questions probed member associations
on the long-term impact of the lack of patient
access to physiotherapy services, lack of
physiotherapists (particularly in Africa) and
provided insights into the stock and gender
distribution of physiotherapists.
7
Human Resources for Health Observer Series No. 28
On average, each organization followed a 2–4 weeks data
collection period approximately, albeit the specific dates
for conducting the surveys varied from 2020 to 2021. Four
organizations (ICN, FDI, FIP, World Physiotherapy) have
reports that discuss either the pandemic specifically or in
conjunction with additional priority issues in 2020. Three
professions (ICN, FDI, World Physiotherapy) conducted
COVID-19-specific surveys in 2020 and two (ICN, FDI)
professions conducted follow-up surveys on COVID-19-
specific surveys in either late 2020 or early 2021. As such,
no unified data collection instrument (and questions)
was applied across all WHPA organizations at a unique
point in time; rather, the organizations gathered data and
developed reports that discuss either the implications of
the pandemic specifically or in conjunction with additional
Table 3: Summary overview of WHPA surveys and reports (2020–2021)
Index Survey and/or report title
Year
Month
WHPA
organization*
Members
count
(approx.)
Members
surveyed
(approx.)
Members
surveyed
and
responding
(approx.)
Response
rate
(%)
Countries,
territories
and
areas
represented
(approx.)
Questions
count
1 COVID-19 NDA Survey 2020 05 FDI 137 137 77 56% 75 15
2 COVID-19 NDA Survey, follow up 2020 12 FDI 133 113 38 34% 28 30
3 Global survey 2021 01 FDI 133 133 63 86% 54 20
4 Pharmacy Workforce Intelligence:
Global Trends Report
2018** 01 FIP 146 146 45–67** 28–51% 75 72
5 Community pharmacy at a glance 2021 11 FIP 146 118 79 67% 79 72
6 Protecting nurses as a top priority 2020 08 ICN 130 52 34 63% 50 21
7 Nurses, A voice to lead 2020 12 ICN 130 130 54 42% 130 64
8 Policy Brief: Nursing education and
the emerging nursing workforce
2020 12 ICN 130 130 64 49% 130 64
9 Impact of the COVID-19 pandemic
on physiotherapy services globally
2020 06 World Physio 125 122 110 90% 122 60
10 Informal data collection on
morbidity and mortality
2020–21 — WMA 116 — — — — —
Averages*** 130 120 58 57–60% 83 38
*FDI: World Dental Federation; FIP: International Pharmaceutical Federation; ICN: International Council of Nurses; WMA: World Medical Association; World
Physiotherapy (no acronym)
**Multi-year surveys (2006–2016), with 75 countries having contributed data for at least two time points
***All averages presented use a denominator of 9 (see index) except for the ‘Members count’ that is divided by 5 (number of organizations).
priority issues. It is important to note that WHO did not
provide either technical or financial support to the WHPA
data collection process. Table 3 presents a summary of
the WHPA surveys in the period between January 2020
and November 2021. The surveyed members of each
organization ranged between 52 and 146 (average 120)
depending on each organization’s membership count,
i.e. whether the entire membership or a subset of the
membership was surveyed. The survey response rate
varied between 28%–90% (average 58%). The survey
questions count among the four WHPA organizations
(excluding WMA) ranged between 15–72 (average 35) and
many questions had sub-questions that were not counted
as additional questions.
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
8
Counts of sample sizes in the results sections indicate
approximations (sometimes with unknown specifics)
because the detail was not readily available. For all but
one organization, the surveys reviewed for this report
were conducted and analysed by the second quarter
of 2021 and used to inform multiple reports, policy
briefs, press releases, amongst others in the same year
(except for FIP that conducts multi-year surveys). At
least three organizations (ICN, FDI and FIP) combined
their analyses to discuss new findings and ongoing,
exacerbated challenges in their relative profession.
Data quality assessment and
analysis
This report is a synthesis of evidence generated by the
WHPA organizations’ surveys and reports during the
COVID-19 pandemic. WHO worked closely with the
WHPA organizations to review the data collected from
the surveys and ensure that the themes of the presented
results were in line with the conceptual framework. Data
was jointly reviewed on a case-by-case basis and some
national data reports which were deemed to be unreliable
were excluded from the analysis. The presentation of
results was also aligned with the standardized indicators
identified under the conceptual framework to measure
and report the multidimensional impact of COVID-19 on
HCWs. Responses for key findings have been presented
in terms of percentages. The overall count of responses
and data source has been included for each finding in
order to provide information about the reporting patterns
as well as refer to the underlying WHPA surveys and
reports for additional reading. For select survey findings
across the five key themes identified in the report, the
authors then corroborated the findings from the WHPA
partner organizations’ surveys of their respective national
associations with relevant emerging evidence from
literature on the four domains of the multidimensional
framework developed by WHO to measure the impact of
COVID-19 on HCWs.
The following results section presents key findings for all
five research themes that were considered by at least two
of the five organizations (for example, HCWs morbidity
and mortality estimates were only collected by ICN and
WMA), based on the prevalent perceptions of the national
member associations of the WHPA organizations and
data that were gathered through the various surveys and
reports. Not all five research themes were addressed
comprehensively within the WHPA surveys and reports.
Even though questions posted to member associations
and the response rates by member associations varied
between organizations, it was still possible to synthesize
general patterns of key findings from the survey results and
reports. Additionally, the diversity of WHPA organizations
made it possible for this study to identify a set of topics
that apply to all organizations.
9
As mentioned earlier, during the pandemic, HCWs have
faced multiple hazards that affected their physical,
mental and social well-being. This evidence synthesis
presents a summary of key findings relative to five themes
(described in the background section), in alignment with
the conceptual framework developed by WHO to assess
the multidimensional impact of COVID-19 on HCWs’
health and social well-being, their working conditions and
their availability and distribution (Figure 2).
Theme 1
Occupational and/or psychosocial factors
affecting HCWs’ morbidity and mortality
levels: mainly related to infections, death,
extreme stress (post-traumatic) and suicide,
increased accidents at work, burnout and
other mental health conditions
Many countries face great challenges in achieving a timely,
accurate, coordinated and standardized data collection on
morbidity and mortality due to COVID-19 at the national
level. More challenging is to collect certified cause-of-
death data by occupation, as well as data on infections
and deaths by equity stratifiers such as gender, age,
ethnicity, etc. Although ICN and WMA continue to make
strong recommendations to their national members on
the need for detailed data collection at the national level,
their members are not practically positioned to do so,
specifically as that would fall outside the scope of their
mission and geographic reach (see Table 3). Some key
findings, however, are presented below.
Infections
In 2020, the ICN survey results and reports revealed
that more than 1.6 million HCWs have been infected in
34 countries1
. Out of a subset of 52 surveyed associations
1
Argentina; Australia; Bangladesh; Brazil; Canada; Chile; China; Colombia;
Congo; Cyprus; Czechia; Denmark; France; Germany; Greece; India; Iran
(Islamic Republic of); Ireland; Italy; Malaysia; Mexico; Nigeria; Pakistan,
Philippines; Portugal; Romania; Russian Federation; Senegal; South
Africa; Spain; Thailand; Türkiye; United Kingdom of Great Britain and
Northern Ireland; and the United States of America.
Results and key findings
that were acutely affected at that point in time, 34 (63%)
reported that on average 10% of all confirmed cases
of COVID-19 infections are among HCWs (ranging
between 1–32%) (9). Countries with adequate reporting
mechanisms reported that nurses were the biggest HCW
group with COVID-19 infections (9). For example, nurses
corresponded to 42% of the confirmed HCW infections
in Mexico which represented the highest percentage of
nurse infections among HCWs in the ICN dataset (9). In the
Islamic Republic of Iran, more than 60 000 nurses were
diagnosed with COVID-19 (20), which equated to 45% of
the country’s nursing workforce (21,22).
In December 2020, ICN updated its reporting and reflected
that on average around 10% of all confirmed COVID-19
infections were among HCWs, with a range of 0–15% (9)
and further noted that more than 90 million people had
been infected with COVID-19, resulting in 1.9 million
deaths worldwide (9).
Representing dentists, FDI reported on five countries’
rates of infections (23), noting that the data suggest that
COVID-19 infection in dental practice may be less likely
than in other healthcare settings, potentially due to several
reasons, e.g. people experiencing COVID-19 symptoms
are unlikely to visit the dentist (24,25) and measures are
in place to reduce this risk in many countries, such as
pre-treatment screening questionnaires (26). Further,
prior to the pandemic, oral health personnel already used
a high-level of personal protective equipment (PPE) (24).
Representing physiotherapists, World Physiotherapy
reported that some member organizations have tracked
biosafety, health and the working conditions of the health
workers during the pandemic. As a result of working as part
of the pandemic response, many physiotherapists have
become infected with COVID-19, and some have developed
long COVID (18). World Physiotherapy responded to
member organization reports of lack of sufficient access
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
10
to PPE with an advocacy campaign “#PPE4PT” (27).
Representing physicians and pharmacists, WMA and FIP
did not collect any information on infection rates.
Deaths
In the earlier months of the pandemic, ICN recorded 3 418
deaths among its member associations due to COVID-19.
These occurred globally between January 2020 – April
2021 and represented 60 countries, territories and areas2
with a range of 1–592 per country.
For WMA, an initial count of the number of physician
deaths reported was 753. For a subset of these notified
deaths that collected age data (n=181, 24%), the range
was 34 to 90 years (mean, 63). The number of countries
reporting at least one death was 16, and the range of
physicians’ deaths within a single country was between
1 and 175. WMA passed the Resolution regarding the
Medical Profession and COVID-19, that cast attention on
the loss of thousands of physicians’ lives practising their
profession and fulfilling their ethical duties and included
many recommendations (28).
FDI, World Physiotherapy, and FIP have not reported
surveying their members for morbidity and mortality
rates. This should not be taken as lack of recognition
of the severe impact the pandemic is having on those
professions, rather that all WHPA organizations reporting
focused on how to continue to best serve their respective
members, despite clear workforce challenges (as
exemplified in the following sections).
For ICN, 48% (16 out of 33) of the national nursing
associations (NNA) reported that in their countries,
COVID-19 has been recognized as an occupational disease
2
Argentina; Australia; Austria; Bahamas; Bahrain; Bermuda; Bolivia
(Plurinational State of); Brazil; Bulgaria; Canada; China; China, Macao
SAR; Denmark; El Salvador; Estonia; France; Germany; Greece; Grenada;
Guatemala; Haiti; Iceland; India; Italy; Jamaica; Japan; Lebanon; Liberia;
Malaysia; Mauritius; Mexico; Myanmar; Nepal; New Zealand; Nicaragua;
Norway; Oman; Panama; Paraguay; Philippines; Portugal; Republic of
Korea; Romania; Russian Federation; Rwanda; Samoa; Senegal; Solomon
Islands; Spain; Sri Lanka; Saint Lucia; Sweden; Switzerland; Thailand;
Togo; Türkiye; United States of America; West Bank and Gaza Strip; and
Zimbabwe.
for HCWs (9) and 45% (14 out of 31) of those countries
started to provide compensation to health staff who
have contracted the disease at work. However, among
those countries providing the right to compensation,
the eligibility of claiming the compensation highly varied
across countries (9).
WMA urged governments to recognize SARS CoV-2
infection as an occupational disease and that the medical
profession be declared a “profession at risk and further
requested that taking care of healthcare professionals be
a priority, especially in the field of mental health” (28).
Stress, trauma, burnout and other mental
health conditions
Mental health and psychosocial (MHPSS) factors resulting
from the HCWs’ occupational environment are a pervasive
hazard and a long-standing issue for HCWs since before
the COVID-19 pandemic. Several unknowns about the
virus that existed in the initial phase of COVID-19 including
its pathophysiology, mode of transmission, susceptibility
and contagiousness, all contributed to community-
wide distress and may have specifically contributed to
increased stress in the workers caring for those with
COVID-19. Supply chain weaknesses struggled to provide
adequate PPE (and other infection prevention and control
(IPC) products). Shifting public precautions resulted in
shifting (somewhat inconsistently) practice directives
that affected HCWs’ ability to deliver care. ICN reported
most pervasively on this topic, emphasizing that nurses
continue to be placed in harm’s way with an uncertain
level of risk (11), that an immense mental health impact of
the pandemic was occurring on health personnel’s lives,
including its impact on their families and loved ones, all
of which have the potential for long-term effects. Although
only the nursing profession emphasized these issues,
other reports in the professions were consistent with
these claims. In the reports provided, the theme terms
that were also explored for relationships among variables
included ‘redeployment’, ‘stress’, ‘burnout’, ‘anxiety/
anxious’, ‘depress(ed/ion)’, ‘distress’, ‘sick(ness)’,
‘absent’, and ‘isolated’.
11
Human Resources for Health Observer Series No. 28
ICN stated that “a global phenomenon of mass trauma is
occurring to nurses since the start of the pandemic” (19).
This includes the ethical dilemmas that exacerbated caring
for patients given their concern for their personal safety.
For example, the American Nurses Association found that
at least 69% (n=10 997) of nurses in the United States of
America said they agree or strongly agree that they put
their patients’ health and safety before their own (29). In
Israel, over 40% (n=231) of nurses greatly agreed with the
statement that they are “scared to care for sick and carrier
patients” and that “caring for sick or carrier COVID-19
patients entails a significant emotional burden” (30).
ICN emphasized that stress conditions for nurses included
key risks of pathogen exposure, long working hours,
psychological distress, fatigue, occupational burnout,
stigma, and physical and physiological violence. ICN also
flagged the potential long-term impact of long COVID on
HCWs. Their survey findings showed close to 80% (n=48,
approx.) of responding NNAs received reports of mental
health distress from nurses working in the COVID-19
response (19). A subsequent survey in 2021 indicated that
over 70% of NNAs had received reports of mental health
distress from their nurses (n=65, approx.) (11). Nurses
also reported feeling isolated from their families and
anxious about the risk of infecting their family members
with COVID-19 (19).
In 2020, ICN identified the increased risk of burnout,
post-traumatic and other stress-related disorders among
nurses and cited that
A study in Wuhan, China of 2 014 nurses from two
hospitals found that about half of the nurses reported
moderate and high work-related burnout, indicated by
high scores of emotional exhaustion (n=1 218, 61%) and
depersonalization (n=853, 42%) as well as low scores of
personal accomplishment (n=1 219, 61%). The findings
showed that 288 (14%), 217 (11%), and 1 837 (91%) nurses
reported moderate and high levels of anxiety, depression,
and fear, respectively. Mental health outcomes were
statistically positively correlated with skin lesions and
negatively correlated with self-efficacy, social support,
and work willingness (31).
ICN also reported that 38% (n=20, approx.) of NNAs
believed their health systems were not well prepared to
support their nurses’ emotional and psychological well-
being (11). Noting that less than 1% of health expenditure
is spent on mental health services, and less than 1% of the
global health workforce is working in mental health, ICN
related the health of nurses, as part of the communities,
directly affects the wealth of a nation (11).
Specific examples at the national level include:
A survey conducted in 13 countries in Africa
revealed that 20% of respondent nurses (n=489)
reported daily depression symptoms during
the pandemic, compared to 2% prior to the
pandemic (32).
In Spain, 80% of nurses report symptoms
of anxiety and increasing burnout (n=1 243
respondents) (33).
In Australia, 60% of HCWs (n=9 518
respondents) reported anxiety, 71% reported
burnout and 57% reported depression, with
predictors for worse outcomes including female
gender, younger age, nursing and allied health
roles, among others (34).
Inadequate protection for HCWs in all health settings
has also led nurses to deal with professional and
ethical questions related to duties of care while it is
also ethically required that nurses promote their health
and safety. These challenges continue to place nurses
in a vulnerable position, requiring them to balance the
competing obligations of: 1) their role in beneficence and
duty to care for patients with rights and responsibilities;
2) inadequacies within their healthcare systems that
are consistent with their rights and duties; and 3) the
protection of themselves and their loved ones (35).
Ensuring the protection of nurses will result in their
increased trust in the health system and their improved
physical, mental and emotional health, thereby improving
the quality of care to patients (11).
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
12
Although WMA did not survey its physician members
on the occupational impacts of COVID-19, preceding
the pandemic, it passed numerous policies on their
professional contexts, such as physician physical and
mental health well-being (36) and their occupational
and environmental safety (37), in which physicians
are recognized as an integral part of public health and
primary health care (PHC). At the onset of the pandemic,
WMA strongly recognized the occupational impact the
SARS CoV-2 virus was having on HCWs in general,
and physicians specifically, and passed the Resolution
regarding the Medical Profession and COVID-19 (28).
FDI and FIP representing dentists and pharmacists
respectively did not survey their members specifically
on MHPSS factors, however, FDI surveys early in the
pandemic focused on other risk/protective factors for
mental health such as access to adequate PPE, appropriate
health emergency guidance, and financial impacts affecting
access to oral health. Likewise, FIP focused on access
to pharmacists, building confidence in vaccines and
distribution of medicines through community pharmacies.
World Physiotherapy noted the value of providing a safe
space for physiotherapists to share experiences of living
with long COVID. Some members of these networks
have highlighted the importance of being able to pace
themselves and feel supported at all levels when returning
to their workplaces (38).
Theme 2
HCWs’ temporary or permanent departures
from service: mainly due to multiple factors
(such as, unmanageable workload, long
COVID, fears of excess morbidity and
mortality given the unpredictable period of
the outbreak or emergency situation, among
others), and/ or other external factors (e.g.
social and environmental)
A wide range of factors are associated with HCWs’
temporary or permanent departures from service, and
key to those quoted and observed is the workload burden
due to the pandemic response. This was reported in
several ways, such as reflections of an unsure/unsafe
work environment, increased demands that had also
diversified, and the need to train new segments of the
HCWs to engage directly in vaccines roll-out.
ICN and World Physiotherapy reported the lack of
representation of their professions at the national level
particularly during the planning and response decision-
making processes (for nurses) or in understanding their
role in the response (physiotherapists). FDI surveyed their
members on representation and opportunities to engage
at the national or regional levels. In the reports provided,
the theme terms that were also explored for relationships
among variables included ‘redeployment’, ‘repurpose’,
‘volunteer hours’, ‘overtime’, ‘unknown/unpredictable’,
‘risk’, ‘exposure/exposed’, ‘leave’, ‘fear’, ‘afraid’, ‘threat’,
‘absent’, ‘lack of appreciation’, and ‘training to administer
vaccine’.
The unmanageable workload
Prior to the COVID-19 pandemic in 2020, ICN projected
a global shortfall of more than 10 million nurses by 2030
(39). They estimated that this number could be close to
14 million nurses in the future because of the ‘COVID-19
effect’ that both exacerbates and expedites the point
of burnout and absenteeism or leaving the profession
entirely (19). Notwithstanding that, nurses account for
around 60% of the health professional workforce around
the world (19).
ICN found that 90% of NNAs (n=58, approx.) are
somewhat or extremely concerned that heavy workloads,
insufficient resourcing, burnout and stress levels related
to the pandemic response are the drivers affecting the
counts of nurses who have left the profession (40) and that
will continue to contribute to an increase in the number of
nurses leaving the profession in the future. Words used
to describe the symptoms were: exhaustion, burnout,
overwhelmed, difficulty sleeping, anxiety, depression, fear
(of infection from carrier patients) (19). Specific examples
at the national level include (19):
The Japanese Nursing Association reported
that 15% (n=2 750) respondent hospitals
across Japan had nurses resigning from their
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jobs, and some 20% (n=38 000) respondent
nurses reported that they had experienced
discrimination or prejudice amid the spread of
the first wave of the pandemic (41).
The American Nurses Association reported that
51% of the surveyed nurses (n=10 997) have
experienced the feeling of being ‘overwhelmed’
(29). Other reports from the United States
showed that 93% of HCWs were experiencing
stress, 76% reported exhaustion and burnout,
and that nurse-to-patient ratios increased three-
fold (n=1 119) (42).
In China, 60% of nurses reported exhaustion and
90% reported anxiety (n=2 014 respondents)
(31).
A study conducted in Israel indicated that over
40% of nurses fear caring for the sick and
COVID-19 patients (n=231 respondents) (30).
ICN survey results and reports also show that the
intention to leave the profession, either during or after
the pandemic, was high (40). For example, the Danish
Nurses’ Organization in 2020 found that 9 out of 10 nurses
(n=1 820) considered looking for a new job (11). Of all
NNAs surveyed in December 2020, 19% (n=10, approx.)
reported an increase in the number of nurses leaving the
profession as a result of the pandemic and cited that the
main reasons for doing so included heavy workloads and
insufficient resourcing and, secondly, burnout and stress
(11). The impact of this trend was particularly pronounced
in Lebanon, for example, where the Order of Nurses in
Lebanon reported that the situation had become critical
because their economy was in crisis as a result of the
pandemic, resulting in a major downsizing in the number
of hospitals and reduced numbers of HCWs as well as
nursing pay (11).
More than half of the NNAs (57%) (n=30, approx.)
surveyed reported that those remaining in the profession
are being asked to undertake activities outside their
normal duties: i) to ensure the quality of care provided
to the population (Portugal); ii) to get what needs to be
done, done (Estonia); and (iii) to expand their own scope
of practice for a specific period (Denmark) (11).
Other examples of additional activities include HCWs
being deployed to COVID-19 isolation or treatment centres
(Rwanda) and anaesthetists that typically work in surgical
theatres being relocated to intensive care units due to the
reduction of elective surgeries (France) (43). For some,
nurses of national relevance3
were allowed to take on
activities during the pandemic which usually are reserved
for physicians, but only in cases where no physician is
available and which became part of the pandemic legislation
(Germany) (11). Accelerating movement to allow more
registered nurses to prescribe medications for the treatment
of opioid addiction also occurred, i.e. in particular, a
programme to support people in rural and remote areas
access the treatments they need (Canada) (44).
On the positive side, ICN reports show that 56% (36 out
of 64) of NNAs reported that there have been positive
changes to nursing’s scope of practice (11): that in 41%
(26 out of 64) of NNAs, there has been an increased
interest by health systems to develop training programmes
for advanced practice nurses (APNs); and that at least
one NNA was in the process of updating their nursing
regulations as part of its review, and that APNs would be
included (Bahamas) (11).
Administering vaccines was also an additional duty that
HCWs were requested to perform, depending upon the
country context and regulations. Representing dentists,
FDI’s survey revealed that of the 57 survey responses,
the countries that granted authorization to the profession
to administer COVID-19 vaccines include: Cambodia,
Colombia, Egypt, India, Indonesia, Lebanon, Nigeria,
Serbia, Slovenia, and the United Kingdom of Great Britain
and Northern Ireland (17%) and that in some of these
countries, dentists have not previously been allowed
to administer vaccines, including the influenza vaccine
3
It refers to nurses that have been recognised as Advanced Practice
Nurses in Germany.
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
14
(45). In that respect, movements to increase dentists’
involvement in vaccination campaigns are also taking place
in other countries. For example, in France the National
Order of Dental Surgeons has called on the government
to grant permission to the profession, but no authorization
has been given to date (45). Further reporting includes
that the Ministry of Solidarity and Health contacted the
Haute Autorité de Santé to issue an opinion on a draft
health emergency decree authorizing new categories of
HCWs to participate in the vaccination campaign (either
by empowering them [to vaccinate] against COVID-19 or
by empowering them to prescribe [and vaccinate]). This
group of new categories was expanded to include dentists,
students of select medical specialities and volunteers,
retired professionals (dentists, doctors, midwives, nurses,
pharmacists, veterinarians), electroradiology technicians
and laboratory technicians (46). FDI further reported
that similar discussions were also ongoing in Australia,
Hong Kong SAR of China, Germany, Ireland, Kenya,
Spain, and Sweden (13) while eleven other countries –
Cambodia, Colombia, Egypt, India, Indonesia, Lebanon,
Nigeria, Serbia, Slovenia, United Kingdom and the United
States – reported granting authorization to administer
vaccines to certain professionals such as dentists who
had not previously been allowed to administer vaccines
or participate in the influenza vaccination campaigns (13).
Representing pharmacists, FIP also reported that the
2020–2021 French vaccination campaign was extended
until February 2021 and pharmacists could vaccinate
the general public as well (beyond only COVID-19). At
the time of the report, it was yet to be determined what
impact increased pharmacist-led immunizations have
played during the 2020–2021 influenza season (47). To
increase support for pharmacist-administered vaccines,
the French Pharmacies’ Health and Social Education
Committee, Cespharm, also released several resources,
including a poster to be displayed at pharmacies offering
flu vaccination, a brochure containing information about
influenza for healthcare professionals, a checklist to
identify at-need patients and a template registry sheet for
vaccinations by community pharmacies (47).
In many public health systems, World Physiotherapy
representing physiotherapists, found that professionals
in their fields were redeployed into other healthcare roles
to support emergency plans to admit inpatients with
COVID-19 (18).
Fears of excess morbidity and mortality
In the earlier months of the pandemic, the lack of
PPE and other necessary supplies, and the continuing
disproportionate access was evident to all WHPA
organizations. The majority of NNAs reported shortages
of PPE in the earlier stage of the pandemic and while this
situation improved over time, many shortages remain. In
August 2020, ICN conducted the first COVID-19 related
survey on its NNAs (52 associations in 50 countries),
a period of high COVID-19 caseloads. Thirty-three
complete responses from 32 countries were received
with a response rate of 63.4%. One response was received
from each of the 33 NNAs, including 11 in the Region
of the Americas (2 NNAs in Mexico), 9 in the European
Region, 4 in the Western Pacific Region, 4 in the African
Region, 4 in the South-East Asian region and 1 in the
Eastern Mediterranean Region. The survey results show
that about a third (11 out of 33) of the NNAs reported
moderate to severe shortages of PPE in primary and
community settings while 45% (15 out of 33) of the NNAs
indicated moderate to severe shortages of PPE in the long-
term care facilities in their countries (9). In a number of
instances, nurses were forced to either buy or make their
own PPE (11). Furthermore, up to 22% (12 of 54) NNAs
reported PPE supplies were either rarely adequate or never
adequate in some healthcare settings (11).
All NNAs reported that nurses had received formal IPC
training or refresher course on PPE use for airborne
transmission. However, over half (18 out of 33) indicated
that the training was provided more than six months
before the start of the pandemic (9). From a planning
perspective, 30% (16 of 54) of NNAs reported that they
had concerns about their country’s approach to IPC.
Startling reports from the survey also indicated that other
basic yet essential IPC measures and materials were not
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adequately provided to HCWs. This included access to
clean water, soap or hand sanitiser (11). These challenges
of increased working hours and lack of adequate PPE and
its associated training resulted in nurses experiencing
mental distress (19).
FDI also reported PPE shortages for dentists for 79%
(approximately 59 of 75) of its member associations (12)
and put forth well-designed questions to gain insight
into this issue (Annex 1). World Physiotherapy likewise
reported that the inadequate access to PPE by the
physiotherapists in the initial period of the pandemic was
significant. For the 110 associations, when categorized by
their regions (that are different from the WHO regions),
the lack of PPE reportedly ranged from 42% in Asia
Western Pacific to 86% in Africa. An African member
organization stated that
“Physiotherapist outpatients stopped attending their
physical therapy visits due to fear of infection. The
physiotherapist lacked PPE capacity to maintain their
practice. Home-based physiotherapy services were severely
limited due to patient requests for discontinuation.
Telehealth was attempted but physiotherapy and patients
lack platforms for delivery.” (18)
World Physiotherapy’s membership network reported that
requests to the government to ensure access to PPE for
physiotherapists had been made and that in some countries,
member organizations donated PPE supplies to their
members to assist physiotherapists to practice safely (18).
In its Resolution regarding the Medical Profession and
COVID-19, WMA advocated for sufficient provision
of equipment and PPE for HCWs, which allows [safe
access to] healthcare and guarantees the availability of
this material in a situation of possible outbreaks (28).
Furthermore, early in the pandemic, WMA supported
countries worst affected by the COVID-19 crisis by
recognizing the huge challenges doctors and other
HCWs are facing in maintaining health systems in
such difficult and demanding conditions. WMA called
upon the international community and governments to
urgently prioritize support and aid to the worst affected
nations, including oxygen, drugs, vaccines, PPE and
other equipment as needed, and to strengthen healthcare
system resilience in the face of future pandemics (48).
Lack of representation in the policy and
planning of the COVID-19 response
Evidence collated by ICN and World Physiotherapy
suggests that the lack of representation at the policy and
planning level has adversely affected their circumstances
in the pandemic response. The evidence demonstrated
that public health nurses (PHNs) are reliable and effective
responders during infectious disease emergencies,
providing safe, effective and non-discriminatory care
to the communities they serve. They have been rapidly
deploying for ‘mobile-strike’ teams, investigating case
contacts, delivering health education, including self-
isolation and quarantine, monitoring health and well-
being, and responding as necessary. Monitoring and
response have been conducted through both telemedicine
and home visits. These highly skilled PHNs have carried
a huge weight of responsibility, particularly in relation
to health education given the rapidly shifting guidance
on COVID-19 (49). ICN states the key role that PHNs can
have in leadership during the current public health crisis.
Despite their critical role, however, in many countries
PHN positions have been underfunded, often eliminated
or under-resourced. This has resulted in a diminished
public health mandate and reduced access to institutional
experience to provide public health services, resulting in
making communities more vulnerable to both chronic and
infectious disease threats (49).
Lacking appreciation and feeling undervalued for their
roles during the pandemic was acknowledged by several
WHPA organizations. For example, ICN reported that
nurses from around the world feel undervalued and that
their true potential is not understood nor appreciated
(further expanded upon in theme five). Usually, this is
evidenced by under-resourcing, lack of representation at
high-level decision-making and artificial barriers created
to stop nurses from working to their full scope of practice
or potential (9).
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
16
World Physiotherapy reported a lack of knowledge about
the importance of physiotherapy treatment and the role of
physiotherapists as HCWs in the response to the COVID-19
pandemic. They felt this was occurring not only among
people affected by COVID-19 but also from different
stakeholders involved in the healthcare process (18).
In the case of oral care, FDI asked their membership about
involvement in areas such as advocacy at the national
and/or regional level, contribution to national data on oral
health indicators and representation and convening of oral
health personnel (14).
Theme 3
HCWs’ access to and uptake of COVID-19
vaccinations: mainly knowledge around
vaccination coverage among HCWs; and
the main enablers and barriers to rapidly
achieving high coverage of COVID-19
immunization of HCWs
The topic of vaccination coverage among HCWs (those
fully vaccinated, partially vaccinated and those with no
access to vaccination) was not surveyed specifically by
any of the WHPA organizations because, like morbidity
and mortality estimations, global member organizations
do not have access to this information. However, surveys
covered key topics concerning HCW being considered
as a priority group for receiving the vaccine, addressing
both enablers/barriers to vaccination coverage (for
the public), and advocacy campaigns for confronting
mis- and dis-information. Spectrums of both trust and
distrust among vaccine-hesitant patients and of mis- and
dis-information affecting the public’s safety concerns
were also discussed.
All WHPA organizations reported on this theme differently
with FIP, representing pharmacists, providing the most
strategy-related vaccination-insights for addressing
challenges related to vaccine reluctance. In the reports
provided, the theme terms that were explored for
relationships among variables also included ‘lack of/
unclear information’, ‘mis-’ and ‘dis-information’,
‘strategy’ and ‘policy’.
HCWs and COVID-19 vaccination
ICN published a Call to Action that states that “nurses
are the largest group of health professionals in the battle
against COVID-19: their safety and well-being should be
a priority for governments and healthcare organizations”
(50), that they are essential to keep our health systems
and emergency response running, and that governments
should commit to prioritizing COVID-19 vaccination for
HCWs once available (9). For dentists, FDI found that
53% of responding countries (n=57) stated that dentists
would be included in priority vaccination groups, 18%
reported that priority groups were still being planned,
and 12% reported that they would not be (45). The
remaining 17% represents the countries that either have
not granted authorization to the profession to administer
COVID-19 vaccines or dentists would not be included
in the priority vaccination groups. Significantly, among
those responding are countries where dentists have not
previously been allowed to administer vaccines, or at
least the influenza vaccine. In the United States, around
20 states are currently permitting dentists to administer
COVID-19 vaccines (45).
In its Resolution on the Equitable Global Distribution
of COVID-19 Vaccines, WMA called attention to the
heightened risk faced by HCWs and vulnerable populations
in a pandemic situation and therefore urges that these
individuals be among the first to receive a safe and
effective vaccine (51).
ICN found that an enabler for vaccine coverage was to
utilise the presence of nurses through public information
channels that strengthen their community integrity and
value, including disseminating vaccine recommendations
that “create a better understanding of health and
healthcare through the nursing voice” (9). Guidelines
and recommendations for HCWs testing for COVID-19
are available in 80% (24 of 30) of the NNAs. In most
countries, however, routine testing of the health workforce
is not implemented (9).
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FDI and FIP also noted the relevance in community
education for their respective professions of oral and
pharmacy care.
Pertaining to the medical practice, the WMA Resolution on
this topic states that “vaccination and immunization have
been acknowledged as an effective and safe preventive
strategy for several communicable diseases. And vaccine
development and administration have been the most
significant intervention to eradicate infectious diseases
and influence global health in modern times” (51).
Examples of the elements for countries to implement
include:
“Element No. 2) emphasizes that no country should be left
behind in the race to vaccinate its population against this
global threat;
Element No. 3) balance the desire of each country to
protect its citizens and the need for the vaccines to be
distributed worldwide;
Element No. 9) coordinated efforts to increase public trust
in vaccination in the face of disinformation campaigns and
anti-vaccine movements which undermine the health of
both children and adults.” (51)
FIP extensively covers vaccination and provides multiple
strategies, recommendations and examples in its toolkit
(52) that aims to support individual pharmacists with tools
for effectively communicating the value, efficacy and safety
of vaccines, and for addressing concerns about or the
rejection of vaccines. It provides a background on vaccine
hesitancy and the main reasons for it as well as ways to
address vaccine hesitancy directly with individuals. It
also includes examples of pharmacy-based campaigns
and information, and guidance on advice for different
types of vaccines is also provided. FIP identified many
barriers for the pharmacy profession rapidly achieving
high vaccination coverage via mass campaigns. They
stated that the success of vaccination campaigns, and
hence the capacity to respond and control a pandemic,
will largely depend on the ability to vaccinate a large part
of the population. They also reiterated the need to address
and overcome what the WHO calls the 3 C’s of vaccine
hesitancy (complacency, confidence and convenience)
(53). These include building trust in:
vaccines’ effectiveness and safety;
systems that deliver them, including the
reliability and competence of the health services
and HCWs; and
motivations of the policy-makers who decide on
the needed vaccines.
FIP did not conduct data collection specific to COVID-19
vaccination refusal among HCWs but referenced the
WHO concerns related to vaccination or outright refusal
to receive vaccines despite availability, as one of the top
10 threats to global health in 2019 (54).
Theme 4
Common causes and key manifestations
of industrial actions, protests, strikes and
lockouts (IAPSLs): mainly related to the
general welfare of HCWs (fair pay, workload,
safety, security)
Causes and key manifestation of industrial actions,
e.g. activities specifically leading to protests, strikes
and lockouts, were not extensively reported. However,
concerns and unrest were expressed on workload burden
and associated safety issues, inequities of treatment, and
violence. The World Physiotherapy collected gender-
related data on their respondents. ICN stated that 90% of
the nursing workforce is female and gender inequality has
been further exposed by the pandemic, including issues of
protection, fair pay, and decent work conditions.
In the reports provided, the theme terms that were
explored for relationships among variables also included
‘salary’, ‘overtime’, ‘double-time’, ‘overworked’, ‘lack of
appreciation’, ‘violent/violence’, and ‘value/valued’.
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
18
HCWs and causes of IAPSLs
ICN reported the key risks of pathogen exposure,
long working hours, psychological distress, fatigue,
occupational burnout, stigma, pay, and physical and
psychological violence as conditions of discontent and
unrest among nurses (11). For example, more than 20%
(n=13) of NNAs expressed significant concerns and unrest
related to the pay of nurses in their countries (10). The
additional occupational risks and the mounting demand
and pressure in work have led to a wide debate of wage
levels and remuneration in some countries, e.g. nurses
went on strike over the working conditions and wages
during the COVID-19 pandemic (Zimbabwe) (9). ICN cited
an independent analysis that identified industrial disputes
and strike action in 84 countries among health workers
since February 2020 (55).
Other safety-specific concerns were reported by World
Physiotherapy. They stated that lockdown restrictions
(and returning from those restrictions) and the definition
of ‘essential physiotherapists’ was not consistent within
and between countries, territories and areas. They also
recommended the development of guidance documents
for HCW clarity (18).
HCWs and issues of violence and
discrimination
ICN reported that around 70% (24 of 34) of the surveyed
NNAs experienced incidents of violence or discrimination
against health workers due to COVID-19 (9). In 2021,
49% (26 of 54) NNAs again reported pandemic related
incidents of violence, assaults, or discrimination against
nurses (11).
For example, in collective country-specific references (11),
the Japanese Nursing Association reported that:
“There are some reports of discrimination, for example,
taxi drivers refused to allow HCWs rides, childcare
services refused to take care of children of HCWs, and
neighbours of home care users are throwing heartless
words that the home visit nurses are spreading the
infection.”
The Indian Nursing Council reported that:
“Tenants asking the nurses to vacate the houses,
during quarantine, discriminating in the allotment of
accommodation, for example the doctors are provided
five-star hotels whereas nurses are given accommodation
in the hostels.”
The Mexican Federation of Nursing Colleges, A.C. reported
that:
“They have been prevented from using public transport,
they have been sprayed with chlorine, their property
(houses, cars) has been torched, they have suffered social
isolation, and they have been asked not to remain in their
own homes. These and other incidents have been reported
to the corresponding legal authorities.”
WMA has been advocating and developing policy for the
protection of medical professionals specifically, and HCWs
in general, in the past two decades. These include the
Statement on Violence and Health (2003) (56), Statement on
the Protection and Integrity of Medical Personnel in Armed
Conflicts and Other Situations of Violence (2011) (57), the
Statement on Violence in the Health Sector by Patients
and Those Close to Them (2012) (58), and the Declaration
on the Protection of Health Care Workers in Situation of
Violence (2014) (59). Country-specific policies have also
been developed for conflict-affected countries, e.g. the
Resolution to Stop Attacks Against Healthcare Workers and
Facilities In Turkey (2015) (60) and the Resolution on the
Protection of Health Care Facilities and Personnel in Syria
(2016) (61).
In the past two years, WMA also passed specific policies
that address the continuation or exacerbation of the violence
during the pandemic period, such as the Resolution
regarding the Medical Profession and COVID-19 to “fight
against violence towards doctors and against any sign of
their stigmatisation by promoting zero tolerance of violence
in healthcare settings” (28) and country-specific contexts,
such as the Resolution in support of Medical Personnel and
Citizens of Myanmar (62).
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Inequalities and inequities affecting HCWs’
social and well-being status
For ICN, the pandemic has increased inequalities and
made nurses realize that optimal levels of health cannot
be achieved without addressing other social and well-
being factors such as housing, education, employment,
living standards, climate and nutrition. They reiterated
that working to eliminate inequalities related to gender,
race, ethnicity, religion and socio-economic position
will lead to better societies in general, and to reducing
conflict and violence, so that everyone will be able to
live more peaceful and fulfilling lives. Addressing gender
inequalities in healthcare, such as biases in data gaps
and access to care is a vital part of the vision for future
healthcare, and one of the most effective ways to improve
the health of society (11).
The FIP COVID-19 reporting included data from 2018 that
linked workforce intelligence (as one of its many global
priorities) to goals that address gender and diversity
balances. It conducted a longitudinal study from 2006–
2016 (and completed before the COVID-19 pandemic)
of its workforce balance on global capacity trends in
the pharmaceutical workforce that included gender
distribution and capacity ground mapped to regional
variation and country-level economic indicators (15).
Forty-one (out of 75 countries, 54%) provided data
on gender in the years of 2009, 2012, 2016.4
Using
properties of regression analysis, FIP estimated an
overall global increase of 16% female participation in
the global pharmaceutical workforce by 2030, resulting
in an estimated proportion of 72% for the total global
pharmaceutical workforce (15).
The FIP report provides a comprehensive overview of
capacity trends, noting its significant contributions
to the understanding of the current, and persistent,
workforce capacity inequities (15). FIP states that without
adequate capacity there cannot be safe and effective
4
Forty-one (out of 75 countries) included in this analysis provided data
on gender. The initial starting date for the data trend analysis was 2009
because no gender-related data were captured from the 2006 survey,
resulting in a reduction to three discrete time data points (2009, 2012,
2016).
use of medicines globally, regionally, nationally, or
locally. Pharmacists will continue to have a crucial role
in vaccination campaigns, both related to COVID-19 and
other immunizations.
World Physiotherapy collected gender-specific data but did
not survey male and female physiotherapists specifically
(18). Nonetheless, having the reporting data by gender
could yield some useful insights into potential inequalities
and inequities among physiotherapists. The remaining
WHPA organizations, as a part of this examination, did not
assess gender specifically and how it relates to inequities
in the workplace.
Theme 5
Detrimental consequences of any of themes
1-4 above, mainly evidence related to the
delivery and quality of health services i.e.,
prolonged service disruptions, interruptions in
HCW education
Service disruptions were reported by the dentists, nurses
and physiotherapists but the pharmacists and physicians
did not survey this topic specifically. Detrimental causes of
the disruptions specific to the HCWs were not extensively
discussed, although WMA has multiple policies addressing
how emergencies and disasters affect physicians, the
populations they serve and recommends medical ethics be
part of the emergency planning to protect people, especially
the most vulnerable (referenced below). Data and findings
specific to service disruption and its impacts on mortality
and morbidity of in-patient care was not discussed, but
implications of these service disruptions were.
ICN, FDI, WMA and FIP (i.e. nursing, dental, medicine,
and pharmacy) refer to service disruptions to the ‘patient’
except for World Physiotherapy that also uses the term
‘client’ when delivering its services. In the reports
provided, the theme terms that were also explored for
relationships among variables included ‘client’, ‘untreated’,
‘missed services/appointments’, ‘lack of staff/services’,
‘suspended/reduced/increased’ of ‘impacts/access to
care’, and ‘morbidity/mortality’.
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
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HCWs and disruptions to essential health
services
Since the beginning of the pandemic, ICN has been tracking
its impact on health worker infections and nurse deaths and
calling for the protection of the health workforce (19). Both
WMA and ICN reported counts of mortality and morbidity
due to COVID-19 early in the pandemic and at a specific
point in time, but the true toll remains unknown and
significantly understates the true impact. ICN referenced
the Centers for Disease Control and Prevention’s (CDC)
position that, due to the pandemic, suspensions of public
health programmes, including the monitoring of tobacco
use, maternal health services, domestic violence (including
child abuse and neglect), mental health and substance use
disorders services would have a compounding societal
impact. For example, female HCWs, were more prone to
poor mental health outcomes and difficulties when facing
stressful situations (63). This evidence synthesis also
considered the results of the three rounds of the WHO
pulse survey that assessed how the pandemic’s impact
has evolved over time regarding disruptions and rebounds
in services and responses, mitigation strategies and
bottlenecks to the implementation of essential COVID-19
tools. In particular, the third pulse survey (responses
received during November–December 2021) continued to
report health workforce mitigation measures are among
the top strategies used to mitigate disruptions with more
than 70% of countries (at least 67 of 95) applying some of
these measures (64).
The third pulse survey results also underscored the
particular concern over the variant waves of Delta and
Omicron (92% of 129 countries) (64). ICN reiterated its
extreme concern about the increased transmissibility of
the new variants of SAR-CoV-2 and the impact of the viral
changes on infection and hospitalization rates in healthcare
workers (19). They called upon governments to take urgent
action to ensure the physical and mental health of nurses
and other health workers, to build health systems that can
deliver the essential public health functions for UHC and
global health security, and provide support for the health
workforce and to develop policy responses to address the
global nursing shortage (19).
Pertaining to the pandemic’s impact on nurses and
healthcare delivery, ICN emphasized that
“The changes to healthcare delivery due to COVID-19
cannot be understated. The combination of lockdowns,
quarantining, misinformation, high bed occupancy rates in
hospitals and a culture of fear have resulted in a dramatic
transformation in the public’s response to seek care when
needed. In addition to this demand issue, many healthcare
services were scaled back, and staff and resources
prioritized elsewhere. Care for chronic health conditions
has been disrupted with early discharges from hospital
to home, rescheduling of non-urgent elective procedures
out/patient appointments and redeployment of staff” (11).
FDI found that dental practices were closed/restricted
during the early period of the pandemic for 50% (38 of
77) countries following a governmental decree, for 39%
(30 of 77) following non-binding recommendations, and
not restricted for 11% (9 of 77) (12). From December
2019–June 2020, they further reported that 90% (69 of
77) countries had practice closures and restrictions with
77% (59 of 77) reporting PPE shortages (12). From June
2020–February 2021, 39% (15 of 38) countries reported
practices closures and restrictions and in 2021, 41% (26
of 63) still reported PPE shortages (12).
Of the World Physiotherapy respondents to their annual
membership census, 87% (96 of 110 members) reported
that physiotherapy practice had been disrupted during the
pandemic in their country/territory, with most member
organizations reporting a disruption of two or three months,
mainly between March and May 2020 (during the first wave
of the pandemic) (18). They further reported that 70% (77
of 110) of respondents reported all physiotherapy services
had been disrupted during the pandemic. Private practice
was the most impacted (87%, 96 of 110), followed by
public health services (81%, 89 of 110), nursing homes
(77%, 85 of 110), and community services (72%, 79 of
110). The Africa region had the lowest levels of disruption
across almost all physiotherapy services and World
Physiotherapy noted that more detailed research needs to
be done to identify whether this is due to a lack of disruption
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to services or to a more general lack of physiotherapists
providing services in the region (18).
One country representative in the South America region,
of which all World Physiotherapy regional members
participated (n=11), reported that
“Outpatient and private care services were suspended,
and many physiotherapists lost their jobs during the first
three months of the pandemic in our country. Later, when
care was allowed, the number of patients decreased due
to protocols and fear. Although digital physiotherapy was
implemented, it is still not a usual practice in our country,
there are several rural places where there is no internet
and physiotherapists do not know how much to charge per
session” (18).
World Physiotherapy has precise counts for their
physiotherapists within each region and their South
American member representation was 432 525
physiotherapists (40% of the global total of 1 091 585)
at the time of the survey collection.
World Physiotherapy also noted that people with long-
term conditions could be particularly affected by the
disruption to physiotherapy services and therefore
remedial strategies should be put in place to address
this issue (18). Further, that people with non-COVID-19
long-term conditions have been particularly affected by
the disruption to physiotherapy services because they are
more likely to develop complications secondary to their
existing conditions (18).
WMA has several long-standing policies that relate
to the issues of interruptions to services and critical
infrastructures due to disasters. In its Declaration of
Montevideo on Disaster Preparedness and Medical
Response (2011), WMA noted that each year disasters
cause hundreds of deaths and cost billions of dollars due
to disruption of commerce and destruction of homes and
critical infrastructure, and that
“The emergence of infectious diseases, such as H1N1
influenza A and severe acute respiratory syndrome
(SARS), and the recent arrival of West Nile virus and
monkey pox in the Western hemisphere, reinforces the
need for constant vigilance and planning to prepare
for and respond to new and unexpected public health
emergencies and called upon its members to advocate to
…work with national and local governments to establish
or update regional databases and geographic mapping
of information on health system assets, capacities,
capabilities, and logistics to assist medical response
efforts, domestically and worldwide, when needed.
This could include information on local response
organizations, the condition of local hospitals and health
system infrastructures, endemic and emerging diseases,
and other important public health and clinical information
to assist medical response in the event of a disaster.” (65)
In its Statement on Medical Ethics in the Event of Disasters
(2017), WMA reminded its members that
“Disasters often result in substantial material damage,
considerable displacement of people, many victims and
significant social disruptions. Adequate preparation would
make major consequences less likely and less severe and
protect people especially the most vulnerable.” (66)
And in its Statement on Avian and Pandemic Influenza
(2018), WMA recommended that
“Physicians should develop contingency plans to deal with
possible disruptions in essential services and personnel
shortages.” (67)
Interruptions in HCW education
Interruptions related to HCW education are a powerful
finding of this evidence synthesis. ICN had extensive
reporting on the impact the pandemic has had on
nursing students and their education. Disruptions of
undergraduate and postgraduate nursing education was
reported in 68% and 56% of countries (n=64) respectively.
Schools were closed, clinical placements were cancelled
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
22
or postponed, and some countries are experiencing delays
of up to a year (11). ICN complemented this with United
Nations Educational, Scientific and Cultural Organization
(UNESCO) reporting that disruptions at all levels will
impact nursing education. “At the peak of the COVID-19
crisis, 1.6 billion learners in 190 countries were impacted
by national school closures worldwide” and further that
“the United Nations reports that both the global economic
impact of the pandemic combined with the effects of
school closures could result in a generational education
catastrophe” (68). This topic is extremely relevant when
considering the multiple and compounding impacts for
the nursing profession specifically that face long-term
profession shortages.
In summary, Table 4 provides an overview of the key
findings relative to each of the five themes.
Theme Key findings
1. Occupational and/or
psychosocial factors affecting
HCWs’ morbidity and mortality
levels: mainly related to
infections, death, extreme
stress (post-traumatic) and
suicide, increased accidents at
work, burnout and other mental
health conditions
• The ICN survey (2020) results and reports revealed that more than 1.6 million HCWs have been
infected in 34 countries.
• As a result of working as part of the pandemic response, many physiotherapists have become
infected with COVID-19, and some have developed long COVID (18).
• ICN created an estimate of 3 418 recorded nurse deaths among its member associations due to
COVID-19 that globally occurred between January 2020–April 2021 in 60 countries.
• Both ICN and WMA reported that in close to half of their members countries, COVID-19 has been
recognized as an occupational disease for HCWs (9,28).
• ICN emphasized that stress conditions for nurses included key risks of pathogen exposure, long
working hours, psychological distress, fatigue, occupational burnout, stigma, and physical and
psychological violence (11).
• World Physiotherapy noted the value of providing a safe space for physiotherapists to share
experiences of living with long COVID (38).
2. HCWs’ temporary or permanent
departures from service: mainly
due to multiple factors (such
as, unmanageable workload,
long COVID, fears of excess
morbidity and mortality given
the unpredictable period of
the outbreak or emergency
situation, among others), and/
or other external factors (e.g.
social and environmental)
• ICN found that 90% of NNAs are concerned that the heavy workloads, insufficient resourcing,
burnout and stress levels related to the pandemic response are the drivers affecting the counts
of nurses who have left the profession and that will continue to contribute to an increase in the
number of nurses leaving the profession in the future (40).
• A number of additional duties were requested from HCWs, depending on the country context
and regulations. These include administering COVID-19 vaccines in the case of dentists, working
in intensive care units in the case of anaesthesiologists, and other HCWs being deployed to
COVID-19 isolation or treatment centres (13,43).
• In some countries, physiotherapists were redeployed into other healthcare roles to support
emergency plans and to admit inpatients with COVID-19 (18).
• All WHPA organizations variably echoed concerns over the inadequate availability of PPE
and other basic yet essential IPC measures and materials (such as clean water, soap or
hand sanitisers), sometimes used with insufficient training. These challenges and the
increased working hours resulted in HCWs (especially nurses) experiencing mental distress
(9,11,12,18,19,28).
Table 4: A selective summary of the evidence of the multidimensional impact of COVID-19 on HCWs under the five
themes
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Theme Key findings
3. HCWs’ access to and uptake of
COVID-19 vaccinations: mainly
knowledge around vaccination
coverage among HCWs; and the
main enablers and barriers to
rapidly achieving high coverage
of COVID-19 immunization of
HCWs
• None of the WHPA organizations had access to information around the COVID-19 vaccination
coverage among HCWs.
• FDI found that 53% of responding countries stated that dentists would be included in priority
vaccination groups (45).
• ICN found that an enabler for vaccine coverage was to utilise the presence of nurses through
public information channels that “create a better understanding of health and healthcare through
the nursing voice” (9).
• FIP did not note data collection specific to COVID-19 vaccination refusal among HCWs but
referenced the WHO concerns related to vaccination or outright refusal to receive vaccines
despite availability, as one of the top 10 threats to global health (53,54).
4. Common causes and key
manifestations of industrial
actions, protests, strikes and
lockouts (IAPSLs): mainly
related to the general welfare
of HCWs (fair pay, workload,
safety, security)
• Causes and key manifestation of industrial actions, e.g. activities specifically leading to protests,
strikes and lockouts, were not extensively reported. However more than 20% of ICN’s NNAs
expressed significant concerns and unrest related to the pay of nurses in their countries (10).
• ICN cited an independent analysis that identified industrial disputes and strike action in 84
countries among health workers between May and October 2020 (55).
• World Physiotherapy stated that lockdown restrictions (and returning from those restrictions) and
the definition of ‘essential HCWs’ was not consistent within and between countries/territories (18).
• In 2020, ICN reported that around 70% of the NNAs experienced incidents of violence or
discrimination against health workers due to COVID-19. In 2021, 49% of NNAs again reported
pandemic related incidents of violence, assaults, or discrimination against nurses (9,11).
• In 2020–2021, WMA passed specific policies that address the continuation or exacerbation
of the violence during the pandemic period, such as the Resolution regarding the Medical
Profession and COVID-19 to “fight against violence towards doctors and against any sign of their
stigmatisation by promoting zero tolerance of violence in healthcare settings” (28).
• The FIP COVID-19 reporting included data that linked workforce intelligence to goals that address
gender and diversity balances. Using properties of regression analysis, FIP estimated an overall
global increase of 16% female participation in the global pharmaceutical workforce by 2030,
resulting in an estimated proportion of 72% for the total global pharmaceutical workforce (15).
5. Detrimental consequences
of any of themes 1-4 above,
mainly evidence related to the
delivery and quality of health
services i.e., prolonged service
disruptions, interruptions in
HCW education
• FDI reported that 90% (69 of 77) countries had practice closures and restrictions from December
2019–June 2020, with 77% (59 of 77) reporting PPE shortages (12).
• Disruptions to physiotherapy practice during the pandemic were reported by 87% of World
Physiotherapy respondents to their annual membership census (96 of 110 members) (18).
• Disruptions of undergraduate and postgraduate nursing education was reported in 68% and 56%
of countries (n=64) respectively (11).
24
The needs and challenges associated with collecting
coordinated evidence-based data at the national level,
particularly in the context of health emergencies and
pandemics, are well known. Unilateral questions about
profession-specific morbidity and mortality counts across
all the professions did not occur. This is likely due to
the limitations of how to do so because most national
associations do not have access to comprehensive and
representative data. The findings suggest that there is
a need to coordinate better and collect more granular
data on gender, age and other equity stratifiers,, so that
differences can be compared not just between various
occupations but among the HCWs of each occupation as
well. The five WHPA organizations, through their networks
of national member associations, can advocate to
countries, territories and areas to prioritize the collection
of this data and thus facilitate the generation of insights
into their professional populations. This will help generate
the evidence to develop a more coordinated, gender and
age responsive, policy response that is inclusive and
equitable.
WHO estimated that between 80 000 and 180 000 HCWs
could have died from COVID-19 in the period January
2020 to May 2021 (3). This indicative range is still an
underestimate given it derives from an overall number
of 3.5 million deaths due to COVID-19 reported to WHO.
In May 2022, WHO estimated that the full death toll
associated directly or indirectly with the COVID-19
pandemic (described as “excess mortality”) between 1
January 2020 and 31 December 2021 was approximately
14.9 million (range 13.3 million to 16.6 million) (69).
As a collective voice for the five organizations, WHPA is
well placed to amplify the HCWs’ needs and challenges
through their data collection, representation and advocacy
at the global level. This assessment has shown that no
single survey question specific to COVID-19 was asked
identically across all five professional organizations.
Therefore, a harmonized approach that is co-developed
by the WHPA organizations would provide unprecedented
insights into how the pandemic has impacted this
professional workforce, especially as the recovery phase
and ‘build back better’ challenges present, as well as help
generate the evidence to establish key policy priorities for
the HCWF. Some key messages are outlined below:
1. Utilize member representation and survey
participation rates
High survey participation rates among each association
were significant, particularly during an emergency response
to a global pandemic. This reflects a core significance and
value of the WHPA. Individual organizations represented
within WHPA show combined skills in survey development,
that, if aligned with the collective insights from this study,
could create a unique focus on the relevant priority issues
as the COVID-19 pandemic transitions into recovery and
rebuilding national health systems. For example, FDI’s
inclusion of facility ownership (public/private sector)
could inform resource trends. World Physiotherapy’s
inclusion of gender questions aligns with the Sendai
Framework indicators (70) that strive to assess equity and
empowerment. ICN’s thorough analysis of professional
education is a predictive indicator that informs global
workforce supply trends. FIP’s workforce surveys not only
provide long-term trend information but prepares their
profession for the expectation of contributing to doing so
regularly (15,16,71). With the average survey participation
rates of 57–60% and a WHO global representation of
approximately 87% of the 194 MS (while averaging 85% in
each of the regions), a carefully crafted survey could yield
unprecedented findings on the state of HCWs in a unique
period of global health security.
The subset of 42 MS where all the five WHPA partner
organizations are present could produce an insightful
subset, albeit the insights would have to be interpreted
with caution given country subsets of disproportionate
Discussion
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Human Resources for Health Observer Series No. 28
vulnerabilities would not be represented, e.g. small island
developing states and countries affected by fragility,
conflict and violence.
2. Advocate for immediate systemic MHPSS
support to the global health and care
workforce
The increased and sustained MHPSS risks to the global
health profession cannot be overstated. Despite not
having the morbidity- and mortality-specific counts, the
multifaceted mental health and well-being impact on
this professional population is profound. The COVID-19
pandemic has made clear that the obligations implicit in
duty of care extend to the systems which support those
personnel (72). The consequences in this multifaceted area
deserve a thorough evaluation. However, implementation
of well-funded solutions is needed immediately:
subcomponents of concern for personal safety (e.g. lack
of PPE, effective protocols, occupational protection),
public image and respect for their mission; depression,
anxiety and PTSD; and inequality and discrimination at the
workplace, for example. Suicide and increased accidents
were not specifically discussed in the reports. The
sensitivity of this topic, and the likelihood of reluctance to
respond transparently combined with the range of cultural
dynamics, would be as equally challenging to quantify as
morbidity and mortality counts.
MHPSS models consider the scope, gravity and toll
that stress can inflict on an individual. The International
Committee of the Red Cross (ICRC), which focuses on
conflict and chronic violence contexts, has a MHPSS
assessment model (73) for approaching this complex
topic. Some HCWs might feel that they have been working
in a chronically unsafe profession since the beginning of
the pandemic, despite not being classified as in a conflict
zone. This topic should be informed by a well-established
format for approaching this issue. A collective MHPSS-
specific assessment would further inform the impact of
the pandemic on this global health profession as well as
harness opportunities to coordinate and act faster and
with more urgency. However, sufficient evidence-based
data exists to demonstrate that for the nursing population,
delivering immediate resources to HCWs is urgent.
3. Integrate value and protection within the
global health and care workforce
Compounding issues changing work environment and
policies, secondary and tertiary impacts of fears and
fatigue, and short- and long-term effects of mental and
psychosocial impacts are negative force multipliers in
the loss of this crucial workforce. Opportunities for
positive retention of this workforce could be found in
the repurposing and expanding of skill sets, as well as
the recruitment of additional workforce, particularly as
the skill set of providing vaccines is applied not just for
COVID-19 but other vaccines as well (e.g. annual flu,
malaria and long-term, well-established needs). This also
supports the concept that HCWs universally should be
considered as a priority group to be vaccinated and as a
priority subset of those who can be trained to prescribe
or distribute vaccines, depending upon their professional
demands (74). The FDI surveys explored this topic most
deeply and provide insight into this possibility for the
dental profession, but further exploration is needed for
the other four professions and the potential ramifications
of this concept to the HCW role.
Utilizing the role of community health personnel such
as community pharmacists in remote areas is a strong
strategy for potentially reaching the unvaccinated. HCWs
that develop a role of trust within the communities could
be a source of clarifying mis- and dis-information. FIP’s
reporting on the potential use of pharmacists – and
potentially applied to a broader health care workforce – is
a solid potential strategy in combatting both protective
messaging (for the HCWs) and misinformation (of
vaccination realities). Importantly, although the shifting
of HCWs into different roles was discussed, reporting
was not found on how the specific shift to distributing
vaccines affects their associated fears or other reluctance
of personal infection protection or by extension, family
infection protection. Repurposing of HCWs should be
carefully considered in terms of potential repercussions,
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
26
including the MHPSS dynamics, and always within the
boundaries of their ethical and professional responsibilities.
Reports of feeling undervalued as a health care
professional are linked to a lack of protection mechanisms,
such as advocacy support, policy development and
legislation implementation that reinforces their value. A
lack of monitoring and surveillance of COVID-19 related
infections among HCWs and the follow-up of the impact to
occupational infections also presents an unknown area of
impact on the profession. Both the nursing and physician
professions (the former through its reporting and the latter
through its policy statements) underscored this need. The
importance of having professional representation at a
prominent level cannot be overstated as the response
phase continues for some countries and the recovery and
rebuilding phases begin for others.
The stress of the pandemic on health systems and the
subsequent short- and long-term strategies for regaining
the ability to care for populations must be informed by
experts that have navigated the systemic challenges
because they are the best informants for the recovery
building back strategies. HCWs’ representation at the
national level is essential. This could be a profound force
multiplier to recruiting, maintaining, valuing, and regaining
trust among health care professionals that are otherwise
inclined to leave the profession for compounding reasons.
Countries are called on to adopt progressive pathways for
investment in the planning and financing, education and
employment, and protection and performance of HCWs
(75). Additionally, new momentum is needed around the
development of a care compact that sets out management
and policy actions structured around four core domains:
preventing harm; providing support; inclusivity; and
safeguarding rights (76).
4. Anticipate data and intelligence needs
and integrate strategic planning for risk
communication in preparedness strategies
for health emergencies
Globally, social media has never been more pervasive,
with constant flows of viral information that range in
quality and content. Health emergency contexts tend to
amplify these flows, and hence the pressure to manage
public messaging is extreme. Organizational strategies
that extend from the point of care to the community,
subnational and national level must anticipate how all
individuals (both giving and receiving care) can become
their own media source. The challenges of the COVID-19
pandemic were unexpected, but specific tools are available
to prepare for media interaction in the context of health
emergencies (77). Best practices for developing robust
strategies that include messages to health workers about
those strategies exist (Annex 3).
Providing situational awareness to the HCWF helps
to generate feelings of being valued and appreciated.
Providing messages that acknowledge and address the
risks to the HCWF during a pandemic assures them
that measures have been taken to protect their safety
and security, and when necessary, that measures also
exist to protect their families. If implemented effectively,
media strategies can not only help protect and inform the
health care workforce but support a message of value
for their roles, both internal to a facility or practice and
how they engage with the public. World Physiotherapy
cited a clear example of how the lack of knowledge about
safe operating procedures and occupational health and
safety for physiotherapy practices during the COVID-19
pandemic was a concern when returning to practice after
a period of lockdown restrictions (18).
ICN reported the most on media forces that impact
the perception of the health care professional in the
broader public forum, citing that 77% of NNAs surveyed
(n=50, approx.) reported an increased frequency of
nurses appearing in the media during the pandemic and
66% of NNAs (n=42, approx.) reported an improved
public understanding of the work of nurses (11). But
the commitment the HCWs make remains not well
understood. For example, the National Consociation of
Nursing Association of Italy stated that:
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Human Resources for Health Observer Series No. 28
“More people know about the role of nurses in health
systems. But this role is often connected as a physician
help profession. The public does respect the commitment
of nurses” (11).
Similarly, the General Council of Nurses of Spain further
stated that:
“Nurses are more in the spotlight now, although there
is still a long way to go to make the nurse’s job more
widely understood. They know that we are there working
hard but they need to understand the independence and
professionalism that we have. There is still a very strong
prevailing cultural belief that the nurse is under the
doctor’s orders” (11).
ICN summarized their findings of public perceptions of
the nursing role specifically, but this perception could
likely be applied to the broader community of these five
health professions:
“The pandemic has brought into clear sight the
relationship, disconnect and weaknesses between
politics, economics, health policy, public health and the
available nursing workforce across the world. This voice
also needs to challenge the public’s understanding of
the profession and move it on from nursing tropes that
serve only to devalue and limit nursing influence. The
discourse needs to illuminate the public that nurses are
highly educated and skilled, autonomous healthcare
professionals who function as part of a team in their own
right. They work in all healthcare settings, including
long-term care facilities, primary health care, high-tech
intensive care settings, acute care and the community.
With unique insight, the nursing profession can move
forward confidentially and powerfully, ensuring that its
voice is not drowned out by others perceived as more
powerful, in shaping the future of healthcare. This is an
essential new reality” (78,11).
Information and communication strategies were developed
in response to the COVID-19 pandemic and some lessons
learned have been applied, as discussed herein. However,
the WHPA professions would benefit from an overarching
assessment of the remaining gaps in these domains
that would deepen collective priority areas of interest.
Preparedness for health emergencies requires multi-year
strategies that further planning activities. Areas of media
content, venues, and languages all need to anticipate
messaging challenges. Proactive rather than reactive
information and media strategies should inform pandemic
recovery and rebuilding. The lessons learnt from the
pandemic are opportunities for prioritizing the issues to
address while complementing them with short- and long-
term visions of how preparedness strengthens building
back better.
Protecting the role of the professions providing direct
medical services from violence is a universal obligation. But
this violence is now pervasive among health professions
in general. Social stigmatization and other associated
taboos of infectious disease exposure have also come to
the fore and exacerbated an already existing challenge of
respect for the roles of the HCW and discrimination and
violence at the workplace.
Developing unified messaging for recovery, rebuilding,
and preparation for the next pandemic is critical. These
strategies can be informed by what has been learned to
date and applied to already established guidelines, such
as the Public Information Officer role that is outlined in
the job action sheets within the United States’ Hospital
Incident Command System that is adaptable to the
non-hospital context and that includes preparation for all
stages of planning for a health emergency (79).
5. Bolster the role of HCWs in leadership and
decision-making levels
WHO and the WHPA organizations have recognized the
need for effective advocacy for HCWs on many topics
within their professions that must be universally achieved,
for example:
Designate the health and care sector as a sector
that puts its personnel at a disproportionate
occupational risk,
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
28
Prioritize HCWs for receiving vaccines, and
Protect HCWs from violence, discrimination and
workplace inequalities.
These require adequate representation of HCWs at the
planning, strategy, and decision-making levels. The
workforce will continue to be vulnerable and bear a
disproportionate responsibility to recover from this and
other pandemics without an adequate representation
or voice. They will remain in the position of having the
responsibility to implement solutions without having
the authority to do so. Deliberate and immediate health
worker engagement at the planning, policy and finance
levels should occur. Without question, doing so would
make great strides in the protection and sustainability of
the global HCWF and the long-lasting MHPSS challenges
that have yet to fully be grasped, including the accelerating
workforce shortages anticipated for 2030 (39,40). The
WHO/ILO guide on health and safety of health workers
also emphasizes that the key elements of a national
programme for occupational health and safety of workers
include “A unit or person in charge of occupational health
and safety of health workers designated within the ministry
of health” as one of nine important recommendations (80).
6. Implement strategies to address societal
inequities and inequalities
Limited reporting existed on ‘key manifestations of
industrial actions, protests, strikes and lockouts (IAPSLs):
mainly related to the general welfare of HCWs (fair pay,
workload, safety, security), occupations and numbers of
workers involved…’ but MHPSS compounding impacts
of treatment at the workplace were heavily discussed by
ICN and FDI. Social inequities and inequalities in the health
workplace have been exacerbated during the pandemic
and have been compounded by professional uncertainty
and fatigue. This impact has been witnessed on the global
scale, including the access to and distribution of vaccines
and on the national levels. Systemic inequities of gender
were reported by both ICN and FIP, representing nursing
and pharmacy respectively; although the FIP COVID-19
reporting included data from 2018, it linked to workforce
intelligence (as one of its many global priorities) and
goals that address gender and diversity balances. World
Physiotherapy tracked male and female physiotherapists.
Depending upon the other variables assessed and how
the data was used in the analysis, this variable is a strong
advancement in relating gender to extremely relevant
issues of national and subnational equity dynamics.
Cross-correlation of variables, e.g. gender, race and
minorities with propensities for violence, treatment at
the workplace, and facility ownership (such as how FDI
collected public/private sector data) could inform more
robust policies and practices that support adhering to
universal obligations. Inequalities also represent a form of
discrimination and are not consistent with the obligations
of the Universal Declaration of Human Rights (1948)
and the International Covenant on Economic, Social and
Cultural Rights (1966) “without discrimination of any
kind as to race, colour, sex, language, religion, political
or other opinion, national or social origin, property, birth
or other status” (81,82).The Convention on the Elimination
of All Forms of Discrimination Against Women (83) is
especially relevant for the health and care sector, in which
women make up over 70 per cent of the workforce (84).
It’s clear that violence at the health workplace is being
reported more, especially for nurses, and these incidents
of discrimination, verbal aggression, physical assaults
are causing psychological distress and that the exposure
will continue to have repercussions within the HCWF.
The pandemic period has given additional global and
national attention to this issue, and the WHPA voice could
additionally support calls to action for the protection of
this critical workforce.
7. Reinforce vaccination communication
strategies
The known levels of vaccination coverage among
HCWs (those fully vaccinated, partially vaccinated and
those with no access to vaccination) are unknown due
to many reasons including availability, accessibility,
willingness, reluctance and other resistance-related
issues. Enablers and barriers to rapidly achieving high
coverage of COVID-19 immunization of HCWs reflect
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Human Resources for Health Observer Series No. 28
the need to engage anthropologists (as has been seen
during the 2015–2016 Ebola virus response), but FIP’s
recommendations on approaches to managing mis- and
dis-information campaigns and utilizing the valuable role
pharmacists play in both communication and community
presence are also applicable to the other four health
professions of WHPA.
Shortages of PPE to protect this workforce were
pervasively reported across WHPA organizations. Fears
of morbidity and mortality about the ongoing impacts of
COVID-19, including spikes in variants, will continue to
motivate HCWs to demand adequate PPE supplies. The
inability of countries to ensure adequate supply of PPE for
HCWs in the third year of COVID-19 is only a geopolitical
choice, not a supply reality. Examples of question topic
areas are listed in Annex 1. Particularly strong references
to this topic are also published (9,11,12,18,19,48).
8. Institute regular monitoring mechanisms
of service disruptions during public health
emergencies
Service disruption data was not extensively collected by
the five health professions. The impacts of disruptions
to immediate and long-term impacts need further
analysis. Metrics should consider the ranges of service
disruptions for prevention, chronic, and emergency care
but, like the collection of morbidity and mortality data,
challenges for doing so include developing consistent
measures within and across the professions, having
access to the data, and acquiring accurately representative
sampling of causal interruption to the patient (client) care
services. Secondary and tertiary impacts, e.g. how lack
of prevention services impacts chronic and emergency
services, other emergencies and disasters that occur in
a given time frame, and contexts of chronic violence and
conflict would compound the challenges of measuring
this precisely. WHO’s approaches to metric development
such as those used in the pulse survey (85) for creating
consistent and standardized metrics among the WHPA
professions could enhance that discussion.
Student HCWs, as the pipeline for meeting the
professional standards of HCWs to fully practice, are a
resource that must be utilized to address the shortfall
and disproportionate distribution of this professional
workforce. Investigation is needed into the collective
global student/in-training workforce and how this
workforce can be expanded and matured to meet the
future demands of the global health professionals,
including the contemporary need for global health security
awareness. The World Association for Disaster Emergency
Medicine’s Mentorship program is a mechanism that
bridges new professionals into the operational context of
an emergency or disaster by not directly inserting them
into the context but instead utilizing their skills as a safe
way to support a response while providing operational
response experience (86).
9. Engage individual reporting expertise from
all WHPA organizations
All WHPA organizations’ reports, policy briefs, press
releases, etc. are well written and dense with insightful
information that is deserving of individual examination. They
articulated their issues and related them to the national or
subnational levels to depict challenges (and where possible,
creative solutions) at the national and local levels. Case
studies and statements from national associations provided
relatable examples. The extensive referencing therein will
be valuable for WHO to further explore if specific areas of
reporting prompt further questions.
ICN was particularly instrumental to its members by
developing checklists and ‘strategies to building trust
in the healthcare systems’ (11) (Annex 3), which is an
effective way to operationalize solutions to the challenges
experienced. If such an instrument were developed and
applied to all WHPA organizations, it would benefit
all the member associations (an examination if these
already exist was not included in this analysis). These
could further be aligned with the International Health
Regulations (IHR) (2005) (87), the Sendai Framework (70),
and other universal obligations and policy frameworks as
means to help simplify these obligations and relate them
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
30
to recovery and essential public health functions that
HCWs are already doing (and as means to clarify those
concepts that can cause confusion).
10. Embed universal obligations, regulations,
and guidelines in strategies that protect
HCWs
HCWs’ primary objective is the delivery of care. Critically,
the WHPA is human-centred, focusing on the HCW as
a fundamental component of health system response,
and it stands behind universal fundamental principles,
recommendations, regulations, etc. as a unified approach
to strengthen and protect health systems and the HCW
within those systems. These include the IHR and the Sendai
Framework, which emphasize the need for multi-hazard
risk management approaches that address biological
hazards such as pandemics and epidemics alongside
natural, environmental and technological hazards, as
well as integrated action across the three dimensions of
sustainable development and across various agreements,
frameworks and conventions, e.g. the 2030 Agenda for
Sustainable Development Goals (SDG) (88), the Paris
Agreement on climate change (89), the Addis Ababa
Action Agenda (90), the New Urban Agenda (91), the
Global Compact for Safe Orderly and Regular Migration
(92), the SIDS Accelerated Modalities of Action (SAMOA)
Pathway (93), etc. Taken together, these frameworks make
for a more complete agenda to deliver essential health
services and essential public health functions and require
action spanning development, humanitarian, climate and
disaster risk reduction areas. This coherence will serve to
strengthen existing risk fragility and frameworks for multi-
hazard assessments, and aims to develop a dynamic, local,
preventive, and adaptive urban governance system at the
global, national, and local levels, for all of which the HCW
is a crucial part of their support and implementation. The
WHO health emergency and disaster risk management
(Health EDRM) framework extends many of the aims of
these universal obligations, regulations, and guidelines
into the operational context of disaster risk reduction for
health by identifying components of these aims and linking
them to activities that operationalize these aims (94).
The HCWF bears significant responsibility for actualizing
universal obligations, regulations, and guidelines that
ensure their protection as well as that of their patients.
They must have operational support to practise policies
and protection strategies to be well-equipped for
the occupational health risks of health emergencies,
including pandemics and have entitlements, e.g., benefits,
compensation and MHPSS support. WHPA is in a valuable
position to inform how countries operationalize their HCW
obligations to increase global health security strategies.
Limitations
First, this report is not a summary of all the WHPA
organizations’ contributions and activities in relation to
the pandemic response; key survey results and reports
were provided to support analysis focusing on five themes
derived from WHO’s holistic framework to assess the
impact of COVID-19 on HCWs. At least one organization
(ICN) has issued another report since the reporting for
this project was completed (95).
Second, terminology use varies among the professions.
Whereas some of the WHPA organizations use “health
professional,” others use “healthcare worker.” “Health
and care worker (HCW)” is the WHO preferred term
for this study. In this report, HCWs refers to the health
professionals of the five WHPA organizations. No specific
definition was provided for the professions, which is
understandable given that most professions are defined
in-country and variances are inevitable. No distinction was
made for “HCWs” across both public and private sectors
(9). Throughout the report, however, terms are used that
reflect the global variations (and to some extent the lack
of standardization) across countries.
Third, the COVID-19 pandemic continues to evolve
globally; many organizations and expert individuals have
published through peer-review, surveying and collecting
data from select populations, to inform the international
community as expeditiously as possible regarding relevant
concerns and indications of trends.
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Fourth, all WHPA organizational surveys mentioned cannot
be interpreted directly into individual reports, i.e. as a
one-to-one analysis. Many reports were informed either
by a single survey or multiple surveys, as in the cases of
ICN (nursing) and FDI (dentistry) or built upon a series
of surveys, as in the case of FIP (pharmacy). All reports
combined survey sampling and industry knowledge
to triangulate findings and many solely provided
percentages in their discussions, not specific survey
participation counts. Therefore, this collective report uses
approximations of sample sizes from the percentages
provided. Further, changing member demographics,
counts and percentages also support interpreting the
numbers as estimates.
Fifth, WHPA organizational member counts cannot be
interpreted equally to country member representatives
because more than one member organization can be
represented within a country. However, in at least one
WHPA organization’s bylaws, more than one organization
representing a country/territory/administrative region
cannot occur (World Physiotherapy). Further, over time
the membership fluctuates, which has continued during
the pandemic (and will continue after the pandemic) and
changes the members survey sizes and the resulting
participant samples. Therefore, the percentages and
approximate sample sizes used herein should be
interpreted as estimations that provide solid indicators
(not precise indicators) of the possible and actual
engagement of the WHPA’s five health professions during
the COVID-19 pandemic.
Finally, the report is a descriptive analysis of the WHPA
organizational surveys. The findings may be considered
as the prevalent perceptions of the national member
associations of the WHPA organizations. Due to the
variance in the number of national associations which
responded to various surveys, the data has been presented
for illustrative purposes only and may not be nationally,
regionally or globally representative, and hence may not
be utilizable as is for HCWF planning or policy-making.
In addition, since most of the WHPA surveys and reports
were conducted during the initial period of the pandemic,
the data may not be reflective of the current situation in
countries and also may not be able to accurately capture
the overall impact of the COVID-19 pandemic on HCWs.
Nevertheless, this report can be considered as a snapshot
in a particular period of time and its five themes and
key findings would be particularly useful for strategic
communications and advocacy to policy-makers, donors,
multilateral organizations, civil society organizations and
communities on addressing the multidimensional impacts
of COVID-19 on HCWs and the importance of investing in,
protecting and safeguarding the HCWF.
32
The primary objective of this report is a synthesis of
evidence generated by the WHPA organizations through
their surveys and reports during the COVID-19 pandemic,
guided by WHO’s standardized framework to assess the
multidimensional impact of COVID-19 on HCWs. Nine core
reports from four WHPA organizations were analysed.
The fifth organization did not survey its population and
instead represented its member support via its policy
development of declarations, resolutions and statements,
providing examples of how WMA addresses relevant
topics to physicians.
Collecting standardized evidence-based data continues
to be a challenge. WHPA organizations continue to
reinforce their critical role as non-state actors in their
approaches to these challenges by integrating metrics
in their reporting that can add insight and improve the
comparability of results. Trust in each organization is
evidenced by their voluntary survey participation rates,
their presence within countries, territories and areas and
how that presence comprehensively overlaps in 42 WHO
MS and is partially represented in 169 WHO MS. Individual
member association representation is not comprehensive,
however, because a single member association of any
country may not represent the entire country.
The five themes examined in this evidence synthesis
have overlaps. The report strongly reflects a diversity of
priorities within the WHPA organizations and provides a
deeper understanding of the occupational risks that the
COVID-19 pandemic has inflicted on HCWs in alignment
with the four domains of WHO’s framework. It reveals the
priority issues for WHPA organizations, that represent 41
million health care professionals, and how they continue
to serve their professions during this protracted health
emergency.
Many of the issues discussed herein have primary and
secondary impacts on HCWs (e.g. disruptions of health
services, shifting functions, vaccination access) as well
as immediate impacts (e.g. safety, security, exposure
to violence) and long-term effects (e.g. educational
delays in those entering the professions, or departures
from the profession entirely). MHPSS challenges have a
pervasive presence across all contexts and professions.
Compounding emergencies and disasters were not
discussed but these circumstances have also occurred
during the pandemic and most certainly exacerbated the
issues discussed herein for HCWs. Issues of recovery
and building back better were not discussed within the
WHPA reports but could be considered for future data
collection efforts.
Future investigation of these issues should involve a
select set of questions that uniformly investigates all
organizations and that builds upon these collective
findings. From this, strategies that guide recovery plans,
policy development and future investments to strengthen
the protection and stability of the HCWF at the national
and global levels can occur. Gaps that may exist within
the HCWs that are relevant to this discussion include
facility-based HCWs that are not represented by the
WHPA organizations and the temporary/transit/volunteer
HCWs that have deployed as surge capacities during
the COVID-19 health response. HCWs occupational
protection is imperative for all, especially in the context
of better preparedness and response to future threats and
emergencies.
Further data collection by WHPA and similar stakeholders
can consider questions outlined in Annex 1 that speaks
to both the WHO-specific themes and the priority areas
identified within this report. Individual organizational
survey questions are provided as examples and
extensively referenced. It can also provide examples of
the WHPA-approved approaches to question design.
This is not exhaustive and should continue to evolve with
evidence-based findings as the world transitions out of
the 2020 pandemic, and global heath recommendations
and directives are identified. For example, HCW protection
Conclusion
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and HCW contribution to health systems strengthening
must reorient itself to core public health principles such
as strengthening equitable access to primary health
care (PHC) for all. The WHPA is central to achieving this
crucial aim.
A longer contribution of these findings and the potential
WHPA role is in developing and strengthening HCWs’
contribution to the health of the patients and communities
they serve via highlighting resources and tools. WHO,
countries and health leaders make concerted efforts
at representing and safeguarding their HCWs but the
pandemic impact has reemphasized the critical ‘whole
of society’ and ‘multi-sector’ collaborative roles as
crucial in global preparedness and health security. An
immediate potential role of WHPA organizations could
be to educate their members on the tools that are
applicable and available to them as they transition into
recovery and building back better within their respective
countries, territories and areas, for example via a better
understanding of how their HCW roles are represented
within the universal obligations, frameworks, and national
policy recommendations as they relate to the SDGs, the
Sendai Framework and the IHR (2005). An opportunity
exists for WHPA interprofessional collaboration to align
its aims in the current timeline structures of 2030. As the
WHO website mentions —
“Another feature of rights-based approaches is meaningful
participation. Participation means ensuring that national
stakeholders – including non-state actors such as
non-governmental organizations – are meaningfully
involved in all phases of programming: assessment,
analysis, planning, implementation, monitoring and
evaluation and the protection of the health and care
workforce that are providing that rights-based assurance”
(96).
The WHPA, through its representation of its member
base, is a crucial non-state actor that can continue to
promote this right by identifying, strengthening ownership
and momentum for, and implementing policy responses
during the recovery phase and in stewarding the future
development of HCWs in the post-pandemic context.
34
Annex 1: A compilation of WHPA
organizations’ survey questions
Annex 1 includes the original questions used by the WHPA organizations in their surveys which were presented in
different question formats and terminologies. This section aims to provide a reference for the information mentioned
in the report and to inform readers of the diversity of contributions by all the global organizations. All questions are
categorized by topics and components.
Key demographics and socio-economics (gender, sector, economic status)
How many men and women are members of your organization? Please only include [professional] members. Please leave
blank if you are not sure of the numbers. The percentage of female [professionals] will be displayed on the [profession]
website [female and males with space for integer]. [(18), survey question 1.2]
• Is this number from an official source (for example, a government department, registration authority or statistical
agency)? [(18), survey question 2.2]
• What is/are the source(s) of data for this number? Please list each source with its web address. [(18), survey
question 2.3]
• Is there more than one professional organization for [professionals] in your country/territory? [(18), survey
question 9.1]
• How many people are practising as [professionals] in your country/territory, even if they are not members of your
organization? Please do not include [students or assistants] in this number. Please use all available sources of
information to get the best estimate. [Free text, integer]. [(18), survey question 2.1]
• Is this number from an official source (for example, a government department, registration authority or statistical
agency)? [Yes, this number is from an official source; No, this number is estimated]. [(18), survey question 2.2]
• What is/are the source(s) of data for this number? Please list each source with its web address. [(18), survey
question 2.3]
• Do the majority of [professionals] in your country work in public or private practice: [a. Majority in public practice,
b. Majority in private practice, c. It is about equal, d. Don’t know] [(12), survey question 3]
• What is the total number of [professionals] in your country or territory (all areas of practice)? [Number Year of
data (if not 2020) Source of data (or “Est.” for estimates).] Additional questions include number of community
[professionals] and number of [support personnel]. [(71), survey question 1]
• Consistent with our previous FIP reports, the standardized unit of measurement of capacity is pharmacists per
10,000 population. It was conducted using member organization email contacts obtained from FIP and website
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information, and conducted at repeated intervals over the time period 2007–17 (2006) data was collected in 2007,
2009 data was collected in 2010 and so on), with follow up for non-responders. Basic headcount capacity data
for each valid country case was standardized with date-specific country population for each data point to provide
a measure of capacity (capacity is measured as “density”, the number of pharmacists per 10,000 population). A
mixed-model repeat measures analysis was performed to assess changes in trend for the pharmacy workforce of
each country in relation to workforce size and capacity (standardized by population) and sub-trends associated
with economic status and gender distribution. [(15), page 9]
Impact of COVID-19
• Do you know the number of COVID-19 infections among healthcare workers in your country? [No, Yes (with field
for text).] [(11), survey question 2]
• Do you know the latest number of deaths from COVID-19 among healthcare workers in your country? [No, Yes
(with field for text).] [(11), survey question 4]
• Has any data been collected in your country on the proportion of [profession] that have been infected with
COVID-19 through their work? [a. Yes: If yes, please provide links or upload files b. No c. Don’t know. Yes, please
specify the number, date and source] [(12), survey question 6]
• How has the COVID-19 pandemic affected your organization’s budget projections for 2021? [Free text] [(18),
survey question 4.2]
• Has your organization carried out any advocacy on behalf of your members during the COVID-19 pandemic?
[Yes/No/Free text] [(18), survey question 4.5]
Impact on mental health
• Questions on the topics of exhaustion, burnout, moral distress, overwhelmed, difficulty sleeping, symptoms of
anxiety, symptoms of depression, post-traumatic stress disorder, suicide or suicidal thoughts, fear (of infection
from carrier patients), heavy workloads, isolation, insufficient resourcing with each defined by example for clarity
(when needed and if possible, by a gradation of impact).
• How often does your association/organization receive reports of mental health distress from [professionals] in
COVID-19 response? [Regularly Sometimes Rarely Never Don’t know / unsure] [(11), survey question 8]
• Do confidential mechanisms exist for staff reporting a mental health concern?
• How prepared is your country and healthcare providers to support the psychosocial well-being of [professionals]?
[5-point Likert scale from not prepared to well prepared.] [(11), survey question 9]
• Other question topic areas/mechanisms that exist in support of HCW well-being, including access to individual
mental health and counselling services, such as 24/7 support helplines, one-to-one therapy with clinicians, peer
support and stress relief programmes.
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
36
• Questions also include:
– Availability of services, e.g. in hospital, clinic, non-work contexts and degree of utility for HCWs and for full-,
part-time and temporary workers, confidentiality of services
– Informal networks to offer peer support
– Available resources for long COVID circumstances
• Questions about the organizational level interventions that may be available to address workplace systems and
culture, specifically on workplace mental health support, identifying barriers to accessing care, and broadly on
the prevention of risk factors, such as improvement of working conditions.
Impact on professional practices
• Is the SARS CoV-2 infection recognized as an occupational disease and that the medical profession be declared
a “profession at risk”. [(28)]
• Has any data been collected in your country on the proportion of [profession] or other HCWs that have been
infected with COVID-19? [a. Yes: Please provide links or upload files b. No. c. Don’t know.] [(13), survey question
5]
• Is there a shortage of PPE (masks, goggles, surgical gowns etc.) for [profession] in your country? [a. Yes b. No
c. Don’t know.] [(12), survey question 5]
• Has practice been interrupted in your country/territory during the COVID-19 pandemic? [1st question Yes/No.
2nd question bullet points below. 3rd question free text for providing details.]
[Profession] in private practice has been interrupted
[Profession] the public health system has been interrupted
[Profession] in community practice has been interrupted
[Profession] practice in [XX] homes has been interrupted Other (please specify) [(18), survey question 5.1-5.3]
• Have [Profession] in your country/territory had difficulties accessing PPE during the COVID-19 pandemic? [Or,
are they still] [Yes/No/Free text]. [(18), survey question 5.5]
• Over the last three months, has there been a reduction or increase in the number of [profession] contracting
COVID-19 as a result of their work? [5-point Likert scale from decrease in the rate of infections amongst
[profession] to Increase in the rate of infections amongst [profession]. Please describe the source of your
information with text field for response. [(11), survey question 10]
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• Currently is there an adequate supply of appropriate PPE provided to [profession] caring for suspected or
confirmed COVID-19 patients in all healthcare settings? [Tick most appropriate box in each column]. [(11), survey
question 11]
• Have governments or health systems issued specific policies to protect [profession] and other HCWs during
COVID-19? [Yes/No/Don’t know/Please describe (text field).] Comment: here a gradation of activities from
recommendations to laws/legislation could be asked. [(11), survey question 17]
• Has your country adopted or committed to the WHO Patient Safety and Health Workforce Charter?[Yes/No/Don’t
know/Comments (free text).] [(11), survey question 15]
• Does your country have any guidance in place for continuing or returning to [professional] practice, such as: modified
treatment protocols, PPE and IPC measures, risk assessment, patient intake procedures or personnel restrictions:
[a. Yes: If yes please provide links/explain or upload files b. No c. Don’t know] [(12), survey question 7]
• Does your [National Professional Association] have initiatives to improve access to PPE for dentists in your
country? [ Yes b. No c. Don’t know] [(13), survey question 4.1]
• Is sufficient provision of equipment and personal protection material (PPE) for HCWs, which allows healthcare
and guarantees the availability of this material in a situation of possible outbreak? [(28)]
• Is the HCW a priority, especially in the field of mental health [(28)]
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
38
Testing and vaccination coverage
• Have [profession] been prioritized to receive testing for COVID-19? [Yes/No/Unknown/Please describe (free text].
[(11), survey question 6]
• Has your government committed to prioritize COVID-19 vaccinations for [profession] and other healthcare workers
once they are available? [Decrease in the rate of infections amongst [profession], Increase in the rate of infections
amongst [profession] [(11), survey question 7]
• Are [professionals] currently permitted to administer COVID-19 diagnostic tests in your country? [a. Yes, to
increase the capacity of the national testing regime. b. Yes, as a point-of-care measure prior to [professional]
treatment. c. No. [professionals] are not permitted to provide tests. d. Not currently, but discussions underway
to permit testing by [profession]. e. Don’t know.] [(13), survey question 13]
• If [a] or [b], Can [professionals] administer (please select all that apply): [a. RT-PCR tests b. Rapid antigen tests
c. Don’t know.] [(13), survey question 13.1]
• Will [professionals] be permitted to administer any forthcoming COVID-19 vaccine as part of your country’s
planned vaccination programme? [a. Yes. b. No. c. To be confirmed, [profession]’ role being discussed. d. To be
confirmed, no discussion of [profession]’ role to date. e. Don’t know.] [(13), survey question 14]
• Are [professionals] in your country permitted to administer influenza vaccines? [a. Yes. b. Not currently, but it
has been permitted in the past. c. No. d. Don’t know.
• Will [professionals] be included in a priority vaccination programme for healthcare professionals (HCPs) in your
country? [a. Yes. b. No, priority HCP vaccination is planned but [professional] are not included. c. No, there is
no priority vaccination planned currently. d. Don’t know.] [(13), survey question 16]
Repurposing, redistribution
• Have [professionals] in your country worked or volunteered in other non-[profession] healthcare roles during
the crisis? [(Please select all that apply) a. Yes, through an official system or programme established by health
authorities, NDA etc. b. Yes, organized by themselves or individual clinics/hospitals c. No d. Don’t know] [(12),
survey question 12]
• Have [professionals] in your country worked, been redeployed or volunteered in other non-[profession] healthcare
roles during the crisis? [(Please select all that apply) a. Yes, through an official system or programme established
by health authorities, NDA etc. b. Yes, organized by themselves or individual clinics/hospitals. c. No. d. Don’t
know. If [a] or [b], please provide links/explain, or upload files.] [(13), survey question 12]
Public image of [profession]
• Do you agree with this statement “There been an increase in the frequency of [profession] appearing on/being
interviewed in the media.”? [Likert scale of Strongly disagree to Strongly agree, Please describe (with text field).]
[(11), survey question 56]
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Human Resources for Health Observer Series No. 28
• Do you agree with this statement “The public has responded positively and publicly in support of [profession].”?
[Likert scale of Strongly disagree to Strongly agree, Please describe (with text field).] [(11), survey question 57]
• Do you believe there has been an improvement in public understanding of the work of [profession]? [Yes, No,
Unknown, Please describe (with text field).] [(11), survey question 58]
Government and regional level support
• In your country, does the government or a formal health agency publish any guidelines for reporting infections
and deaths from COVID-19 in healthcare workers? [No, Yes (with field for text).] [(13), survey question 6]
• Does your country currently have any guidance in place for practicing [profession] during the COVID-19 pandemic:
e.g. modified treatment protocols, PPE and IPC measures, patient intake procedures, etc. [Please provide links
or upload files for all types of guidance issued since [Date]: a. Yes: If yes please provide links/explain or upload
files. b. Yes, already provided guidance through the last survey and no updates are available. c. No. d. Don’t
know] [(13), survey question 6]
• Has your government provided, or does it plan to provide, any subsidies or financial assistance to ensure people
in need can continue to access [professional] care during the current economic crisis? [a. Yes: If yes, please
provide links/explain or upload files b. No c. Don’t know If [a] or [b], please provide links/explain, or upload files]
[(12), survey question 10]
Coordination support
• What other actions has your organization taken to support your members during the COVID-19 pandemic? (please
select all that apply)
COVID-19 specific education or training (face to face)
COVID-19 specific education or training (online)
Reduced/subsidised membership fees
Facilitated access to PPE for physiotherapists
Other (please specify) [(18), survey question 4.7]
• Other suggestions:
– How to manage communications, e.g. disinformation, misinformation
– Advocacy-specific messaging
Communication campaigns and advocacy
• Has your organization provided any COVID-19 specific information or resources for your members? (please select
all that apply):
– [Practice based resources (for example, clinical guidelines, practice management, IPC, publications)
– Information for patients
– Education based resources. Information relating to professional regulations
– None] [(18), survey question 4.4]
• Has your organization carried out any advocacy on behalf of your members during the COVID-19 pandemic?
[Yes, No] Follow up: If you answered Yes to question 4.5, please provide details [Free text.] [(13), survey question
4.5-4.6]
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
40
• Has your organization provided any COVID-19 specific information or resources on vaccine reluctance for your
members? [Please select all that apply.]
• See also FIP’s report on building vaccine confidence and communicating vaccine value: A toolkit for pharmacists
[(52)]
Registration and regulation
• Since the pandemic began, have there been any changes to [profession] registration or regulation to fast track
[profession] re-entering (re-registering) the workforce? [Yes/No/Unknown/Please describe with (with text field).]
[(11), survey question 32]
• Has there been an increase in the number of people re-entering (re-registering) the workforce? [Yes/No/Unknown/
Please describe (text field).] [(11), survey question 33]
• Have students in their final year of study been fast-tracked into the [profession] workforce? [Yes/No/Unknown/
Please describe (text field).] [(11), survey question 34]
• Has your government fast-tracked work permits for foreign [professionals] who are already in your country but
had not been fully registered? [Yes/No/Unknown/Please describe (text field).] [(11), survey question 35]
• Have there been any changes to regulation regarding the [profession]? [No changes, Negative changes, Positive
changes, Positive and negative changes, Please describe if these are temporary or sustained/permanent (text
field).] [(11), survey question 36]
Reasons for leaving the profession
• In [date], was there a change in the number of [professionals] leaving the [profession]? [5-point Likert scale
from less left the profession, about the same (mid-point), more left the profession.] If not a concern, please skip
the question. [(11), survey question 21]
• If yes, why? [5-point Likert scale for each of the following]
– MHPSS, from mental health (burnout) to psychosocial concerns (depression)
– Morbidity, from individual to family concerns
– Workplace violence, from concerns of threats to actual incidents
– Inequalities, from subtle to overt discrimination
– Conditions, including lack of/delay in acknowledgment, benefits, pay, etc. [(11), survey question 9]
• [5-point Likert scale from Major reduction in the number leaving, Same number leaving (midpoint). Major increase
in the number leaving, with option for text field response.]
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• Has your country or health system committed to increasing the number of [professionals]? [Yes/No/Unknown/
Please describe (with text field).]. Comment: Follow up to Yes, ‘How?’ with table of options or text field. [(11),
survey question 28]
• What is the recruitment of overseas educated [profession] to your country? [(11), survey question 29]
• What is the recruitment of overseas educated [profession] from your country? Comment: modify table above.
• Has your country committed to improving the retention of [profession] currently in employment to assist in
addressing current or future shortfall in the [profession] workforce? [Yes/No/Unknown/Please describe (with
text field).] [(11), survey question 31]
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
42
• Does your government have a professional representative at XX level, e.g. local, regional or national? [Yes/No/
Unknown/Comment (with text field).] [(11), survey question 37]
• Is this role actively involved in the XX level decision-making process, e.g. local, regional or national? [Yes/No/
Unknown/Comment (with text field).] [(11), survey question 38]
• Have there been any reported COVID-19 related incidents of violence, assaults or discrimination against
[profession] in your country? Comment: This question needs to be informed by the WHPA organizations in how
they think violence might be affecting their professionals. A grid of options should be included. [(11), survey
question 59]
Education and training
• Is your association actively engaging with student [professional] organizations? [Yes/No/Unknown/Please describe
(text field).]
• If yes, is this/are the student [professional] organization(s) helping to fill gaps in the COVID-19 professional
response? [Yes/No/Unknown/Please describe (text field).]
• If yes, a result of the pandemic, has there been a change in the interest in the number of applicants applying to
study [profession] [5-point Likert scale from Major reduction in the number of applications/Same number of
applications (centre of scale)/Major increase in the number of applications, with option for text field response.]
[(11), survey question 25]
• Can [profession] working in private practice [and/or public practice] in your country/territory vaccinate others?
[What restrictions, protocols apply). [Yes/No/Unknown]. [(18), survey question 15.1]
• What is the impact of the outbreak on [professional] education in your country? [a. All classes stopped b. Only online
theoretical classes held c. Online theoretical classes held and urgent clinical procedures performed by students d.
Online theoretical classes held and urgent clinical procedures performed by professors e. No change – all education
proceeded as normal f. Other, please provide links/explain or upload files] [(12), survey question 14]
• Is this current practice guidance compulsory? [a. Yes, compulsory for all [profession] b. Yes, compulsory for
public sector [profession] only c. Yes, compulsory for private sector [profession] only d. No. e. Don’t know.]
[(13), survey question 16.1]
Financial implications
Is any data or information available about the financial impact of the outbreak on [professional] practices in your country,
for example related to lost earnings, practice closures, job losses or trends in patient visits? [a. Yes: If yes, please provide
links or upload files b. No c. Don’t know] [(12), survey question 9]
43
Human Resources for Health Observer Series No. 28
Future of the profession
What are the top five priorities for your country’s health system moving into the future? Comment: This question needs
to be informed by the WHPA organizations in how they think violence might be affecting their professionals. A grid of
options should be included and not only free text. [(11), survey question 62]
What are the top five issues your [professional] organization will be addressing over the next year? Comment:
This question needs to be informed by the WHPA organizations in how they think violence might be affecting their
professionals. A grid of options should be included and not only free text. [(11), survey question 63]
44
Annex 2: Countries, territories and
areas not included in WHPA-WHO-MS
representation
Countries, territories and areas where WHPA has
representation but are not WHO Member States (n=10)
Countries, territories and areas where WHO Member States
do not have WHPA representation (n=25)
Aruba
Bermuda
China, Hong Kong SAR
China, Macao SAR
Chinese Taipei
Guam
Holy See (Vatican)
Kosovo
Liechtenstein
West Bank and Gaza Strip
Antigua and Barbuda
Brunei Darussalam
Burundi
Central African Republic
Comoros
Djibouti
Dominican Republic
Equatorial Guinea
Guinea-Bissau
Kiribati
Lao People’s Democratic Republic
Libya
Maldives
Marshall Islands
Micronesia (Federated States of)
Nauru
Niue
Palau
Saint Kitts and Nevis
San Marino
Tajikistan
Tonga
Turkmenistan
Tuvalu
Vanuatu
45
Annex 3: Lessons learnt and best practices
published by members of WHPA
This reporting would be remiss not to include the ICN recommendations given their pervasive reporting on the nursing
profession before and during the COVID-19 pandemic. The key recommendations are listed below, with commentary
provided.
1. Implement standardized data collection on HCW infections and deaths (9). A more refined strategy on how this
activity could be implemented is needed among the WHPA organizations, such as the inclusion of relevant equity
stratifiers like age and gender. It may be that identifying, rather than implementing, where the resources are now;
as data collection has likely developed differently in countries. However, WHPA could develop recommendations
for standard metrics (e.g., vaccinations per 100 individuals or vaccinations per 100 HCWs) so that they are cross-
comparable and therefore more standardized for resource allocations, supply chains, etc.
2. Capitalize on the current societal value of the HCW that is recognized by the public. In global health history, never
has the HCW been pervasively and universally recognized and revered for its societal role as they have during the
COVID-19 pandemic. Every country has demonstrated its fragility. Increased funding, policies, reinforcement of
policies, and intersectoral long-term strategies that extend from the local to the country levels are crucial to preventing
societal impacts of health emergencies.
3. Strengthen government policies and actions to reduce the count of nurses that are leaving the profession by
improving retention strategies (40). “Whole of society” and “whole of government” approaches (97) are the most
effective way to strengthen health systems that can deliver essential health services and EPHFs at the local level.
WHPA could take a collective role in educating national members on these concepts and making recommendations
on how to approach doing so. WHO’s Glossary of Health Emergency and Disaster Risk Management Terminology
(98) is a solid tool for clarifying term use.
4. National health emergency frameworks are necessary to include nursing students in pandemic preparedness and
response planning. This topic is highly relevant and deserves a distinct section in HCW education curricula (10).
5. Recognize COVID-19, and other equally severe workplace exposures, as an occupational risk (9). The WHO/ILO
guide on health and safety of health workers (2022) also supports this direction (78).
6. Ensure sufficient provision of appropriate PPE and evidence-based IPC training for HCWs in all healthcare settings
(9). Supply chain management of materials and supplies is more likely to be assured and provided if local vendor
relationships are established and maintained well in advance of a crisis; now is the time to establish and maintain
those relationships.
7. Commit to a zero-tolerance approach to violence and discrimination against nurses and other HCWs (9). Strategies
for how to implement such systems exist and can be distributed to national associations. Implementation and
reinforcement of protection policies are necessary. Further, four of the five WHPA organizations are partners with the
What the COVID-19 pandemic has exposed: the findings of five global health workforce professions
46
ICRC “Community of Concern” for the Health Care in Danger Initiative and play roles in advocacy for the prevention
of violence against HCWs.
8. Reorient healthcare system planning to primary health care as a mechanism to ‘creating health’ within societies
that ultimately reduces the acute care demands.
For further information on the ICN’s recommendations, please check the various publications from ICN (9-11,40).
47
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