Existing workers were encouraged or mandated to increase their workload

Many countries modified leave and work schedules to increase the short-term workforce capacity of health care systems (Williams et al., 2020b; Buchan, Williams & Zapata, 2021; Köppen, Hartl & Maier, 2021; WHO, 2021b). Specific strategies included cancelling leave or suspending rest time, asking workers to take on additional hours or move from part- to full-time work, or mandating overtime. In Greece, for example, leave of absence was revoked for all public-sector staff (Williams et al., 2020b); Canada enacted legislation cancelling HCW vacations and modifying their work schedules (Williams et al., 2020b); and the United States shortened guidelines for quarantine/isolation periods in 2021, in part to mitigate HCWF shortages by allowing workers to return sooner (CDC, 2016).

Workers were moved to areas of high demand and public investments in HCWF development programmes helped to increase supply in rural and underserved areas

Changing epidemiological situations and differences in starting capacities meant that demand for HCWFs differed both within and across countries. In response to these challenges, countries took steps to facilitate movement of HCWs from low- to high-demand regions. The United Kingdom, for example, implemented digital National Health Service (NHS) staff passports to enable staff to change posts more quickly and avoid repeated training (NHS Providers, 2020); Peru created mobile brigades of health professionals to deploy to critical areas of need across the country; and in the United States, emergency federal and state policies allowed reimbursement for HCWs practising outside their home licensure state, waived licensing regulations for interstate practice, expedited emergency licences for out-of-state providers, and recognized out-of-state licences through reciprocity (CMS, 2020; FSMB, 2022; NCSBN, 2022).

Some countries introduced public investments in HCWF development programmes to increase the supply and distribution of the HCWF in rural and underserved communities (ASPE, 2022). For example, the United States increased public funding for the National Health Service Corps, which provides scholarship or loan repayment as a financial incentive for practice in an underserved setting, and for the Teaching Health Center Graduate Medical Education programme, which funds primary care physician residency and nurse training programmes in underserved areas. (ASPE, 2022).

Increasing the workload of the existing workforce can increase a health system’s capacity in the short term, but endangers the health and well-being of workers and can put patients at risk

Encouraging or mandating additional work hours can increase a health system’s capacity during times of heightened demand (Rubinson et al., 2005; Mascha et al., 2020) and HCWs have acknowledged the necessity of their extra efforts during prior disease outbreaks (Corley, Hammond & Fraser, 2010). However, these strategies are rife with challenges and are unsustainable over extended periods. A review of national nursing surveys assessing the effects of pandemic-related demands reported significant workload increases (Australia, Egypt), pervasive ‘unfair treatment’ such as forced shift changes (Republic of Korea), and work hours that frequently extended beyond those contracted (United Kingdom). These contributed to poor mental and physical health, exhaustion and fatigue, turnover intention, and potential post-traumatic stress disorder (PTSD) among HCWs (New Zealand Rural General Practice Network, 2020; Grimm, 2021; Buchan, Catton &, 2022; Poon et al., 2022). Ample evidence also demonstrates that long shifts (12+ hours), overtime work, and long work weeks (40+ hours per week) significantly increase the risks of medical errors and patient safety accidents (Rogers et al., 2004; Son, Lee & Ko, 2019; Assaye et al., 2021).

Redeploying HCWs to areas of high need may be valuable for the receiving communities, but consideration for the effects on workers and their home regions is warranted

International cooperation strategies and the easing of requirements to facilitate practice across regions increases HCW mobility to meet population health needs, including during times of heightened demand like public health emergencies. In South America, agreements with the United Nations Refugee Agency, US Agency for International Development, and Cuban Ministry of Health resulted in the recruitment of 150 and 85 health professionals in Columbia and Peru, respectively (WHO, 2021b). A survey of 10,000 HCWs in the United States who received temporary licences to practise in New Jersey found they originated from every state in the country, provided COVID-19 and non-COVID-19 care, conversed with patients in 36 languages, and expanded the state’s respiratory therapist and nurse workforce (Nguyen et al., 2022). The mobility of nurses in the United States also increased when licensing laws were relaxed to facilitate worker movement across regions (Shakya, Ghosh & Norris, 2022). Scope-of-practice laws, determined at the state level in the United States, have been associated with HCWF distribution and access. For example, full scope-of-practice policies are associated with nurse practitioner movement from more to less restrictive states (Shakya, Ghosh & Norris, 2020; Markowitz & Adams, 2022), and with increased supply of nurse practitioners in rural and underserved settings (Xue et al., 2018).

Strategies to facilitate HCW mobility may be especially valuable for localized emergencies and are commonly used in response to weather-related disasters (Coates et al., 2021). However, the utility of these strategies may be diminished when there is widespread need, as was the case during the height of COVID-19 pandemic surges. Further, redeployments to areas of critical need may impact HCWs negatively. A qualitative study examining the experiences of frontline HCWs redeployed to Wuhan, China, during the initial COVID-19 outbreak found that they experienced emotions of shock, fear and loneliness, rooted in a lack of knowledge about the virus, unfamiliarity with the new environment, and concern for their safety. Language barriers were also cited as a barrier to care delivery (Li H, 2022). Cultural and contextual barriers and challenges around integrating with local services have also been identified as issues associated with HCW redeployments in reviews of the evidence for emergency HCWF strategies (Coates et al., 2021).

Investments made in HCWF development programmes during the pandemic are unlikely to see short-term returns. This is especially so considering that many segments of the HCWF – e.g., primary care and public health – are not possible to scale up in the short term since they require training, experience and good knowledge of local communities. They nevertheless support some of the most promising evidence-based strategies for increasing the future supply of HCWs – especially primary care clinicians – for rural and underserved communities, which will likely lead to long-term returns (Ziemann et al., 2022b).

Increasing the workload of the existing HCWF was often not enough, and additional HCWs had to be brought in

Increasing the workloads of existing HCWs or moving them around was usually not enough to cope with increased demand for services during the pandemic. Most countries also had to recruit emergency workers to ensure adequate HCWF capacity. Specific strategies included: recruiting students; bringing back retired or otherwise inactive workers; hiring foreign-trained workers that were in the country but not yet working in the health sector; using workers from other government sectors (e.g. military) and those from the private sector. While many of these strategies were successful at increasing HCWF supply in the short term, each had drawbacks which may impact their long-term usefulness.

Many countries put in place procedures to allow medical and nursing students to enter clinical practice early, serve as health care support extenders, or provide other assistance

Health professions students have often been recruited to augment the existing HCWF during emergencies, and this is a recommended strategy in emergency preparedness plans (Stachteas, Vlachopoulos & Smyrnakis, 2021). During COVID-19, health professions students were generally used to increase HCWF supply in two ways: 1) by entering clinical practice early; and 2) by serving as health care support extenders by addressing the social and other non-clinical needs of HCWs, patients and community members (Iserson, 2020; Williams et al., 2020b; Stachteas, Vlachopoulos & Smyrnakis, 2021).

In the United States, Canada and many countries in Europe, medical and nursing students nearing graduation were allowed to graduate early to join the workforce and relieve pressure on existing frontline clinicians (Iserson, 2020; Williams et al., 2020b). In the United Kingdom, 24,000 final-year student nurses and doctors were recruited to work in the NHS (BBC News, 2020). Several countries in South America, including Bolivia, Colombia, Ecuador and Peru, also took steps to expedite the entry of qualified health professions students or recent graduates into the HCWF (WHO, 2021b). In Peru, for example, degree procedures for medical students were temporarily removed to facilitate their entry into the workplace, while residency requirements in some specialties were ended early (WHO, 2021b).

Strategies to leverage students as health care extenders to increase health system capacity outside of providing clinical care were also employed in many countries, for example, by assisting with contact tracing and COVID-19 hotlines, supplying food and PPE, educating the community, and by enhancing existing workforce capacity through provision of services for frontline clinicians (Iserson, 2020; Stachteas, Vlachopoulos & Smyrnakis, 2021; Umar et al., 2022).

Retired and otherwise inactive workers were sometimes brought back into the workforce

Campaigns calling for inactive or retired health professionals to rejoin the workforce were launched throughout all WHO regions (Iserson, 2020; Williams et al., 2020b; WHO, 2021b; WHO Regional Office for Africa, 2021). Early in the pandemic, the Governor of hard-hit Lombardy, Italy, appealed to all HCWs who had retired in the past two years to rejoin the HCWF (Balma & Pollina, 2020). In Chile, allowing retired and inactive health professionals to return to duty resulted in 1,500 HCWs re-entering the medical field (WHO, 2021b).

Countries facilitated employment of foreign-trained professionals

Prior to COVID, many countries relied heavily on foreign-trained HCWs with the share of foreign-trained doctors around 40% in Norway, Ireland and New Zealand, and the share of foreign-trained nurses up to 20–25% in Australia, Switzerland and New Zealand (OECD, 2020a). When COVID-19 emerged, some countries modified immigration policies to fast-track the licensing and recruitment of foreign-trained health professionals already in the country but not working (Williams et al., 2020b; Buchan, Williams & Zapata, 2021; WHO, 2021b). Ireland allowed for the hiring of refugees and asylum-seekers with medical qualifications to serve in support roles (Williams et al., 2020b). Columbia waived registration fees, provided temporary licences, and expedited the recognition of foreign licences (WHO, 2021b). Some countries have also seen or are taking steps to increase international recruitment. In the United Kingdom, international nurse registrants reached a two-decade high in 2021/22. In Australia, the cost of flights, relocation fees, and quarantine costs for foreign nurses were covered (Buchan, Catton & Shaffer, 2022). In Canada, the Manitoba province announced in November 2022 that it will offer up to $23,000 to international nurses to practise in Manitoba (Province of Manitoba, 2021). As of the end of its 2022 legislative session, the United States Congress was considering legislation to expand the country’s J-1 visa waiver programme, which facilitates immigration of foreign-trained physicians in exchange for practice in underserved settings (Library of Congress, 2021–2022).

Volunteers and ‘reserve’ workers have been used in clinical and non-clinical – including public health – roles

As they have in previous disasters and public health emergencies (Coates et al., 2021), countries also used potential and existing pools of volunteer and ‘reserve’ workers with and without formal health care experience to increase HCWF capacity during COVID-19 (Iserson, 2020; Williams et al., 2020b). For example, France’s health reserve swelled from 3,800 to 22,800 registrants by March 2020 (OECD & European Observatory on Health Systems and Policies, 2021b). Sweden reported registering more than 5,000 volunteers in a matter of weeks after appealing to the public for assistance (OECD & European Observatory on Health Systems and Policies, 2021f).

Other ‘reserves’ called upon by countries for pandemic response included using pools of health workers employed in the national military (e.g., Spain, Germany) in support and logistic roles, and the Red Cross (e.g., Belgium) (Iserson, 2020; Williams et al., 2020b; Köppen, Hartl & Maier, 2021; OECD & European Observatory on Health Systems and Policies, 2021e). In Hungary, the recruitment of hundreds of volunteers and deployment of soldiers to hospitals contributed to the country increasing the total number of intensive care beds by 44% over one year (OECD & European Observatory on Health Systems and Policies, 2021c).

Volunteers and ‘reserve’ workers were used for a range of roles. In the Maldives, for example, volunteers were mobilized for case investigation, contact tracing and psychosocial support teams (Usman, Moosa & Abdullah, 2021). In Cyprus, volunteers assisted with appointment scheduling for PCR testing at public health centres (OECD & European Observatory on Health Systems and Policies, 2021a). Reservists, such as those in the United States’ Medical Reserve Corps, were also used in a variety of clinical and non-clinical support roles (Doran, Hess & Andersen, 2022).

The pandemic has provided a window to expand intersectoral collaboration and create new health workforce roles. One example is the establishment of a Border Health Protection Unit (BHPU) in Fiji, which is now in the process of being embedded in policy and practice (Box 4).

Box 4

New health workforce roles were established through intersectoral collaboration, such as the Border Health Protection Unit in Fiji.

There is little evidence of the wider effects of the targeted recruitment efforts implemented during COVID-19

The limited evidence available suggests that the strategies countries employed to quickly increase the supply of clinical and non-clinical HCWs through the targeted recruitment efforts described were effective, based on short-term process measures of outcomes such as the number of volunteers registered (WHO, 2022b). However, there is a dearth of evaluative data on the strategies, and their effects on broader health system outcomes, a deficiency that has been noted elsewhere (Coates et al., 2021; Gupta et al., 2021). Scarcer still is any evidence for the effects of these strategies on specific demographic sub-groups, such as women, who make up the vast majority of the HCWF in many countries across the world. Understanding around the effect of recruiting any single group (e.g., students, retired health workers or volunteers) is also difficult as most countries recruited multiple groups as part of a larger national surge capacity strategy.

Using students provided valuable opportunities for training but the associated supervisory requirements may have put strain on the already overburdened staff

Much of the literature examining the effects of recruiting health professions students in response to emergencies focuses on students’ perceptions of their experiences. Students reported multiple advantages to volunteering in public health emergencies, including real-world learning and practice opportunities, collaboration with other types of HCWs, strengthened communication skills and empathy, and increased comfort managing COVID-19 patients, donning and doffing PPE, and completing transitions of care functions (Pravder et al., 2021; Umar et al., 2022). Those who graduated medical school early to work in hospitals during the first wave of the pandemic believed their experience would be helpful in their future residency training and practice (Pravder et al., 2021). Evidence also suggests lower prevalence of anxiety and depression among student volunteers compared to non-volunteers (Umar et al., 2022), and that students were safely enlisted in pandemic response efforts without contracting COVID-19 (Pravder et al., 2021).

However, the evidence suggests that some health professions students were also deterred from joining the pandemic response due to perceived threats of infection or harm, scarcity of PPE, uncertainty about academic demands, uncertainty about possessing sufficient qualifications, and perceptions that they were not needed in the response effort (Umar et al., 2022). While concerns have been raised that COVID-19 may diminish interest in the health professions, early application and enrolment data from nursing and medical schools in the United States suggest the opposite (AACN, 2021; Mitchell & Gooch, 2021). Experts have posited that the application surge is partly due to increased motivation to join the pandemic response and alleviate social injustices (National Academy of Medicine, 2022).

Despite the valuable contributions of health professions students, their supervision also requires consideration when determining their involvement and roles, especially in already overburdened regions where frontline staff are limited (Stachteas, Vlachopoulos & Smyrnakis, 2021).

Recruitment of retired health professionals has raised concerns about the associated risks to their health

There are some concerns around the recruitment of inactive health professionals – particularly retirees – as they are likely to be older and have risk factors that make them more susceptible to severe illnesses like COVID-19 (Iserson, 2020). HCWs over the age of 50 experienced significantly more COVID-19 deaths, compared to matched controls (Lin et al., 2022). In one study examining COVID-19 deaths among physicians, the average age was 63.7 years (Ing, et al., 2020). Additionally, recruiting retired clinicians may endanger their spouses, who are also likely to be older. To alleviate the risk of infection, retirees may be considered for low-risk settings, especially where they can make use of remote consultations (Sabath & Colt, 2020).

Some private-sector attempts to surge HCWF supply have had negative outcomes

While the private sector strengthened the capacity of health systems during the COVID-19 response, cautionary tales also emerged. The United States’ experience with private contract nurses is detailed in Box 5. Private-sector partnerships in Nigeria, Senegal, the Democratic Republic of Congo and Uganda supported testing, procurement and distribution of PPE for HCWs, plus COVID-19 treatment and management, among other activities. However, concerns arose around regulatory compliance, high service fees, poor surveillance and reporting, and a general lack of guidance on private-sector engagement in times of emergency (Kabwama, 2022). In the United Kingdom, the operation of a private call centre to support contract tracing was criticized for inadequate training of call handlers, accidental sharing of private contact information, and inappropriate follow-up with positive COVID-19 cases (BMA, 2020).

Recruitment of foreign-trained workers raises many concerns, and this may increase due to workforce pressures

Policies to fast-track the recruitment of foreign-trained HCWs during the pandemic have facilitated marked increases in entrants over short periods of time in some high-income countries, especially among nurses. Using foreign-trained workers can bring positive effects for increasing diversity (as discussed in the companion policy brief of this series ‘What steps can improve and promote investment in the health and care workforce?’ by McPake et al., 2023), but there are also ethical considerations around the effects on these HCWs and their origin countries. Many of these foreign-trained workers originate from low- and middle-income countries (LMIC) such as India, Nigeria and the Philippines (Shaffer et al., 2022). Expert bodies caution that while the international recruitment of HCWs may seem to be a ‘quick fix’ to HCWF shortages, it is neither an equitable nor efficient solution (OECD, 2020a; Shaffer et al., 2022). It does not address structural factors that affect the supply and demand for HCWs, and it threatens HCWF sustainability in origination countries with existing health system weaknesses.

In 2010, the WHO Member States adopted the WHO Global Code of Practice on the International Recruitment of Health Personnel (WHO, 2010) and in 2020 the Health Workforce Support and Safeguards List (SSL) was published by the WHO, comprising 47 countries that faced the most pressing health workforce challenges related to UHC (WHO, 2020b). In January 2023, eight more countries were added to the SSL, increasing the number of countries that need additional protection against active international recruitment to 55. Yet, there are early signs that international recruitment is growing and efforts are needed to tackle both the push (such as poor working conditions and low pay) and pull (better pay and career development) factors of migration in countries of origin and destination (see the companion policy brief ‘What steps can improve and promote investment in the health and care workforce?’ in this series by McPake et al., 2023).

While volunteers can play a key role to support HCWF capacity under emergency settings, it is difficult to predict and plan for their willingness to respond under different circumstances

Evidence from the broader literature suggests that volunteer response during emergencies is influenced by many factors, and pre-registration may not be very predictive. Prior examinations find that the type of emergency, perceived severity of emergency, and perceived threat to the volunteer or volunteer’s loved ones are factors that influence volunteer willingness to respond (Devnani, 2012; Errett et al., 2013; Santinha, Forte & Gomes, 2022). Self-efficacy (the perceived ability to perform one’s duties), has also been identified as a leading predictor of willingness to respond to emergencies, and efforts to increase it may enhance volunteer response capacity (Errett et al., 2013). However, there is limited evidence on the use of volunteers on patient outcomes.

HCWs were redeployed from settings where non-essential services were limited, performing new tasks or roles

Sharp increases in intensive care and hospital demands during the multiple waves of COVID-19 required health systems to flex their workforces. One strategy was to redeploy HCWs from hospital units or health care settings where ‘non-essential’ services were limited. In these cases, role delegation occurred to maximize the use of redeployed staff, while existing HCWs (e.g., respiratory technicians and others) often took on new roles. Similar redeployment, reskilling and new roles were seen in outpatient and public health settings to meet new needs and maintain health care services.

For example, dental teams were redeployed for COVID-19 testing in Singapore (Seneviratne, Lau & Goh, 2020), and pharmacists and other health professionals were authorized to extend prescriptions, prescribe chronic disease medications, and provide vaccines (OECD, 2021b). Meanwhile, community pharmacists were allowed to extend existing prescriptions and prescribe chronic disease medications in France, Ireland, Portugal and the United States (OECD, 2021b). Nurses played a particularly important role in redeployment, reskilling and new roles (Box 6).

Box 6

Nurses played a critical role in the health workforce during COVID-19.

Community health workers (CHWs) were trained to perform new tasks, such as contact tracing, and deployed to explicitly address the needs of underserved communities through provision of community outreach and wellness checks, providing home delivery of medicines, and connecting patients to critical health and social services (Méllo, Santos & Albuquerque, 2022). In New Zealand, where the Māori people face ongoing health disparities, the District Health Boards partnered with Māori health providers to deploy CHWs to deliver health care services such as immunizations, well-being assessments and social support (Cram, 2021); in South Africa, Metropolitan Health Services, a public-sector primary care provider, established home delivery of medications by CHWs in Cape Town (Brey et al., 2020); and in New York City, CHWs conducted telephone wellness checks with over 9,600 individuals living in underserved communities and addressed social determinants of health by connecting patients to food pantries, benefits, vocational training, rental assistance and immigration resources during the initial COVID-19 wave (Peretz, Islam & Matiz, 2020). Later, the City deployed more than 4,000 contact tracers who were largely hired from the communities hardest hit by COVID-19 (Blaney et al., 2022). The United States government subsequently increased funding for CHW training (White House, 2022).

Patients and caregivers embraced greater responsibilities, thereby reducing the burden on overstretched health and care workforces

The strain on HCWs in combination with mitigation efforts to reduce disease spread further pushed health systems to empower patients and caregivers to take on greater roles in their own care. For example, the United Kingdom introduced payment for remote patient monitoring (RPM) using pulse oximetry for COVID-19 (Pronovost, Cole & Hughes, 2022), as well as self-administration of treatments traditionally administered by HCWs; caregivers in Austria were allowed to provide basic health care usually restricted to HCWs; and in the United States, pharmacies could dispense injectable contraception for self-administration (DHCS, 2020). These strategies during COVID-19 are part of a larger movement to empower patients and support self-management, in recognition that individuals must be at the centre of health care and health systems.

The impacts of skill-mix interventions within hospital, primary care and community care settings requires further investigation

Countries implemented diverse strategies to optimize the HCWF during COVID-19, but evidence on their impacts on patient outcomes is limited. Expanded scope-of-practice policies to enable a wider range of health professions to vaccinate, helped expand the scale and pace of COVID-19 immunization deployment in many places. One study suggests that clinical outcomes for tiered staffing models were comparable to traditional staffing models during the pandemic (Stempek et al., 2021). The literature on CHWs during COVID has largely described different programme initiatives (Méllo, Santos & Albuquerque, 2022), with early studies reporting on the delivery of services, such as the number of completed contact tracing cases (Blaney et al., 2022). The larger CHW literature beyond COVID-19 reveals diverse interventions with CHWs working across disease areas and in different roles, ranging from clinical service delivery to care coordination, health education provision, data collection, community engagement and psychosocial support provision (Scott et al., 2018). While some studies show no significant effects on outcomes, there is a growing body of evidence suggesting that CHWs have positive impacts on patient behaviours, health care utilization and health outcomes (Viswanathan et al., 2010; Kennedy et al., 2021; Mbuthia, Magutah & Pellowski, 2022).

In non-crisis periods, greater intensivist physician and nurse staffing are associated with lower patient mortality (Wilcox et al., 2013; Rae et al., 2021). However, models employing hospitalists, telemedicine, resident physicians and advanced practice clinicians have shown positive outcomes, although baseline differences in ICUs (e.g., large academic vs community ICUs) should be considered in the implementation of different staffing models (Garland & Gershengorn, 2013). A 2019 Cochrane review of hospital nurse staffing models found the addition of advanced practice nurses did not have negative impacts on patient mortality; however, other patient and health system outcomes were uncertain. Evidence on models to add nursing assistant personnel is limited (Butler et al., 2019).

In primary health care of patients with chronic conditions, there is growing evidence that skill-mix interventions have at least equivalent or positive impacts on patient outcomes. Evidence on health system outcomes (e.g., cost savings and health care utilization) is more limited and mixed, with some studies showing benefit while others show no difference or occasionally increased utilization. Interventions used advanced practice roles, nurse-led clinics, CHWs, patient navigators, care coordinating roles and team-based care (Winkelmann et al., 2022). However, more research is needed to clarify the scope of practice of different health care roles, optimized team configurations for different settings (Meyers et al., 2018) and the implications for access, quality and cost of care.

Home monitoring and self-administration of medicines may also be beneficial and should be studied further

Home and remote patient monitoring for COVID-19 was effective in guiding care escalation and reducing unnecessary contact with the health care system in some cases. While evidence is limited on patient outcomes (Alboksmaty et al., 2022), one study in the United States found that high-risk COVID-19 patients enrolled in a RPM care model experienced lower rates of hospital utilization, cost of care and mortality (Haddad et al., 2022). Use of RPM has increased in recent years, mainly for chronic conditions, and is conducted through diverse platforms including smartphone apps, wearables and biosensors. Overall, RPM has been shown to reduce the acute care needs, suggesting potential benefits to patients and health care systems (Vegesna et al., 2017; Taylor et al., 2021). Self-administration of medicines has also been conducted successfully for a variety of diseases (Herth et al., 2021) and, specifically, has been shown to be safe and effective for the injectable contraception depot medroxyprogesterone acetate (Curtis et al., 2021). However, RPM and self-administration of medications will require resources and new staffing and delivery models. Challenges in the implementation of these services will include ensuring equitable access and patient privacy around device-collected data and the electronic transfer of patient data across settings (Malanchini et al., 2021).

While studies suggest self-management has positively impacted outcomes, the evidence for reduced service utilization remains weak. In addition, patient self-management will require HCWs serving in new roles, and education and training for current HCWs to effectively integrate self-management into overall care (Nolte, Merkur & Anell, 2020).

The use of telehealth was surged in many countries to maintain delivery of health services

Prior to the pandemic, health systems were making slow progress in integrating new technologies into health care. Regulatory barriers and limited payment often hindered these efforts. However, the pandemic drove a number of emergency policies to expand digital health in order to meet changing COVID-19 needs and maintain continuity of health care services in the face of public health constraints. Digital health tools were used in four principal areas in response to COVID-19: communication and information; monitoring and surveillance; supporting provision of health care services; and vaccination, immunity and pharmacovigilance (Fahy, Williams & COVID-19 Health System Response Monitor Network, 2021).

A notable example of digital health tools being used during the pandemic was the rapid expansion in telehealth consultations to increase the reach of HCWs and maintain service delivery during highly infectious waves of COVID-19. In Norway, the share of teleconsultations in primary health care rose from 5% before the pandemic to nearly 60%; in France, the number of teleconsultations neared 1 million per week in April 2020 compared to about 10,000 per week before March (OECD & European Observatory on Health Systems and Policies, 2021b); and in the United States, telehealth visits increased 63-fold for the Medicare programme in 2020 (Samson et al., 2021). Notably, one scoping review of telemedicine in LMIC during COVID-19 highlights that most evidence was from middle-income countries and, even in these studies, lack of infrastructure and weak/slow internet connections were frequently reported as barriers to successful implementation (Mahmoud, Jaramillo & Barteit, 2022). Appendix 2 provides several examples of different telehealth modalities advanced during COVID.

Targeted use of telehealth helped to mitigate inequitable access to the health workforce within and across countries

The targeted use of telehealth was also employed to mitigate inequitable access to the HCWF during COVID. Examples of targeted telehealth include: a tele-ICU programme in India, connecting district hospital doctors with off-site multi-specialty ICU teams (Rangappa et al., 2021); a cross-border tele-ICU programme connecting the University of California San Diego Health System with two border community hospitals in Mexico (Ramnath et al., 2021); and emergency funding for enhancing telehealth services in federally qualified health centres in the United States (ASPE, 2022).

Evidence on tele-ICU models is promising

While tele-ICU existed before the pandemic, these programmes increased in many countries such as the United States, Israel, the United Kingdom, Egypt, India, China, Brazil, Mexico, and Malaysia in response to COVID-19. Models were diverse, but early evidence suggests tele-ICU was well received by HCWs, expanded ICU capacity, and supported more evidence-based care with decreased ICU mortality (Kemp Van Ee et al., 2022). A scoping review of tele-ICU studies through the first year of the pandemic suggests tele-ICU has been implemented in three areas: extending coverage (often to community-based settings); improving compliance for patient safety and best practices; and facilitating transfer from one ICU to another. Length of stay, mortality, compliance and economic benefits are well documented for the first two areas (Guinemer et al., 2021).

Uptake of telehealth may improve access – however, not everyone may be able to benefit from this equally

Very early evidence suggests that telehealth uptake due to COVID may translate to increased access. One study found that high telehealth availability in federally qualified health centres in the United States was associated with increased visits for patients with mental health diagnoses and greater likelihood of timely follow-up after an emergency department visit (Cole et al., 2022).

Disparities in implementation and access to telehealth during COVID are also apparent. For example, reports of telehealth programmes in Africa are limited; in Japan, the use of telehealth is higher for individuals with university degrees compared to those with a high school diploma or less, and for residents in urban areas compared to those living in rural areas (Omboni et al., 2022); and in the United States, Black and rural Medicare beneficiaries also had lower telehealth use compared to their White, urban counterparts (Samson et al., 2021).

Effects of telehealth needs to be further investigated

Further evidence is needed to fully understand the impact of telehealth and what factors and policies are associated with better outcomes. The United States government is conducting a mixed-methods review to examine: the characteristics of patients, providers and health systems using telehealth during COVID-19; benefits and harms; successful interventions and strategies; costs and return on investment; and policy and reimbursement considerations (AHRQ, 2021b).

Countries implemented strategies to mitigate COVID-19 infection risk among HCWs

Lack of sufficient supply of and access to high-quality PPE, such as N95 masks, for HCWs was of critical concern at the outset of the pandemic. Shortages of PPE were reported globally, necessitating policies and guidelines to optimize limited supplies early in the pandemic. Responding to these insufficiencies, countries (e.g. Mauritania, Niger, Togo) developed and implemented plans to monitor PPE supplies, increase their stockpiles – particularly N95 masks – and distribute them in sufficient quantities to HCWs (Hou et al., 2020; Buchan, Williams & Zapata, 2021; WHO, 2021b, 2022b; WHO Regional Office for Africa, 2021). Beyond increasing and distributing HCW safety supplies, countries provided workers with infection prevention and control training. This covered the proper use of PPE and biosafety, and was often facilitated by e-learning tools (WHO, 2022b).

Some countries introduced policies or programmes to universally screen (non-symptom-based) cohorts of HCWs to identify and track COVID-19 infections (WHO, 2021b, 2022b). Most countries established strict isolation and quarantine restrictions in health care facilities to protect patients and HCWs. Long-term care facilities are especially susceptible to virus transmission, and many OECD countries implemented measures to ban personal visits, isolate affected residents and minimize staff movement between facilities to mitigate the risk of COVID-19 infection for vulnerable residents and LTC workers (Curry & Langins, 2020; OECD, 2021c). Many countries also implemented remote health consultations for non-urgent care to protect patients and HCWs from infection (see Section 2.2.3).

The emergence of COVID-19 vaccines represented a turning point in the pandemic, and many countries prioritized their HCWs in vaccination strategies

COVID-19 vaccines became available in late 2020. In line with calls from international bodies to do so (WHO, 2022a), countries swiftly adopted policies and programmes to vaccinate HCWs as priority populations in their national vaccination plans (Dooling et al., 2020; Palmer, Nemer & Menne, 2021; WHO, 2021b). Some countries issued mandates for the vaccination of HCWs.

HCW protections from rising rates of violence during the pandemic usually occurred at the organizational or work-level, but examples of national efforts also exist

Levels of violence against HCWs increased after COVID-19 emerged. Measures implemented to combat violence against HCWs during the pandemic were often focused on organization- or workplace-level interventions to: improve communication skills and de-escalation techniques; enhance security at the workplace; and implement violence reporting and monitoring. Enhanced accountability, stakeholder coordination, and risk assessment and management strategies were also common. Less frequently, legislation was enacted as a countermeasure (ICN, 2022).

Provision of adequate PPE and other risk mitigation efforts were essential to reduce risk of infection and death

There is strong evidence that use of adequate PPE, especially N95 masks, prevents COVID-19 infection among HCWs (Cattelan et al., 2020; Liu et al., 2020; Griswold et al., 2021; Suzuki et al., 2021; Schoberer et al., 2022), and that access to it is associated with willingness to work during a public health emergency (Devnani, 2012). However, sufficient PPE alone is not enough to eliminate the risk of infections in workers, highlighting the need for additional strategies to augment worker safety (Nguyen et al., 2020a). The lack of measures to protect workers – particularly access to high-quality PPE – increases HCWs’ risks of physical harm, including COVID-19 infection and death (Nguyen et al., 2020b), as well as adverse psychological outcomes, burnout and turnover intention (Brooks et al., 2018; Buchan, Catton & Shaffer, 2022; Poon et al., 2022). Additionally, support initiatives which do not carefully consider the specific needs of their target populations may have unintended consequences. For example, HCWs suffered harmful impacts of PPE, including skin damage, heat stress and other adverse physical events (Galanis et al., 2021), thus demonstrating the importance of policies and practices around HCWF working hours which bear in mind that the PPE HCW will need to wear should not be used for extended periods.

Other risk mitigation efforts have also shown promising results in detecting COVID-19 among HCWs and increasing HCW biosecurity competencies (Evans et al., 2021; Hernandez-Perez et al., 2021; Mostafa et al., 2021; Tabari et al., 2021; WHO, 2021b). A subset of HCWs in China who received infection prevention training, provision of high-level PPE, and accommodation in designated isolation hotels, did not test positive for COVID-19, despite having frequent contact with patients infected with the virus. A comparative control group had rates of infection between 3.4–5.4% (Hou et al., 2020).

Measures to isolate and minimize physical interactions, while identified as effective public health strategies to reduce infection and mortality during disease outbreaks (Leichsenring, Schmidt & Staflinger, 2020; Talic et al., 2021; Thomas, 2021), can also cause emotional and psychological harm, especially to residents in LTC facilities (Gordon et al., 2020; OECD, 2021c). Examination of Dutch guidelines permitting limited visitations in nursing homes for family members meeting specific criteria reported a positive impact on the well-being of patients and no new COVID-19 infections (Verbeek et al., 2020). The effects of expanded adoption of remote digital health technologies are discussed further in Section 2.2.3, but multiple studies identify reduced COVID-19 risk as an advantage of remote consultations for primary care physicians (Verma & Kerrison, 2022).

Vaccinations for HCWs helped reduce infections, but there are inequalities in access and other barriers to uptake

COVID-19 vaccines are effective at preventing infection and severe disease among HCWs (Benenson et al., 2021; Pilishvili et al., 2021; Chano et al., 2022). Across OECD countries, high vaccination rates have also been associated with reductions in hospitalizations and deaths of residents in LTC facilities (OECD, 2021c). However, in addition to vaccine hesitancy (which is higher in women, those of younger age, and those from low-income countries compared to their counterparts), geographic disparities in access to COVID-19 vaccines have served as barriers to the successful vaccination of all HCWs (Sen-Crowe, McKenney & Elkbuli, 2021). Low- and middle-income countries lagged their high-income counterparts in procurement and administration of vaccines, while high-income countries harboured half of the world’s vaccine supply (OECD, 2021d). Experts warn that achieving global vaccine equity is critical for reducing the potential emergence of new variants and for pandemic recovery (OECD, 2021d).

Organizational zero-tolerance policies have been advocated to protect against workplace violence, which has seen a rise during the pandemic

There is inferential evidence to support the effectiveness of strategies health care organizations worldwide implemented during COVID-19 to combat HCW violence, as they align with recommended best practices released by the International Committee of the Red Cross and partner organizations in the wake of the pandemic (ICRC, undated). According to the report’s authors, the evidence for these practices (such as risk assessment and preparedness, communication with the public, security coordination, and monitoring and documentation of violent incidents) is based on first-hand experiences in humanitarian contexts worldwide. One country that implemented many of these recommended practices is Portugal: it took a comprehensive approach to combatting HCW violence with measures including security protocols, staff support, training, an online incident reporting system, and a national security survey of health institutions. The country reported a decrease in violent episodes against HCWs following the implementation of these measures, despite strong incentives to report such incidents (ICN, 2022).

Organizational zero-tolerance policies for any form of violence, including threats, against HCWs have been advocated for as one of the best protections health care employers can offer their staff (Murthy, 2022; OSHA, undated). There is some limited evidence for the effect of these policies on decreasing workers’ tolerance toward aggression (Middleby-Clements & Grenyer, 2007), although researchers point out the lack of clarity in defining aggressive behaviour, especially among patients, as a complicating factor with these policies (Hassankhani & Soheili, 2017).

The strategies implemented within and across countries to support the mental health and well-being of HCWs during COVID-19 primarily focused on individual-level mental health services

There was an urgent need worldwide to adopt measures aimed at protecting HCW mental health and well-being during the COVID-19 pandemic. In countries across Europe and Asia, for example, efforts were implemented by national and regional governments, professional associations and academic institutions to establish helplines offering psychological support and mental health referrals, and to provide remote counselling services, peer support services and mindfulness sessions (WHO Regional Office for South-East Asia, 2019; Williams et al., 2020a). The Australian federal government established a confidential digital mental health service where HCWs can access a range of self-guided and person-to-person resources and services. It has been used by at least 50,000 HCWs in the country (Abdul Rahim et al., 2022). Confidential services delivered through digital interventions were especially valuable as they could be accessed with less fear of losing jobs or being stigmatized.

Countries in South America also took steps to protect HCWs’ mental health by issuing mental health plans for the employers and national entities responsible for worker health and safety (WHO, 2021b).

Strategies to support the mental health of HCWs at the individual level may attenuate some of the effects of workplace stressors, but fail to address their organizational and systems-level drivers

The strategies implemented within and across countries to support the mental health and psychological well-being of HCWs during COVID-19 primarily focused on individual-level interventions reliant on help seeking, consistent with broader efforts to address burnout observed prior to the pandemic (National Academies of Sciences, Engineering and Medicine, 2019). There is some evidence to support the effectiveness of individual-level interventions in improving psychological well-being among HCWs before (Waterman et al., 2018) and during the pandemic (Fendel, Bürkle & Göritz, 2021; Llorente-Alonso et al., 2021). However, for long-term impact, consensus bodies assert that systemic, multipronged efforts to address the organizational and systems-level drivers of poor mental health and burnout are required (National Academies of Sciences, Engineering and Medicine, 2019; Murthy, 2022). Organization-level interventions may specifically include those for workplace mental health support, such as identifying barriers to accessing mental health support and awareness raising for all staff; and, more broadly, on prevention of risk factors, for example, reductions in workload, schedule changes, or improvements to communications and teamwork.

Interventions addressing factors like excessive workload, inadequate staffing, administrative burdens and lack of job control, can support HCW mental health and well-being, with benefits for patients

A growing body of evidence identifies promising systems-level strategies that target the drivers of burnout, moral distress and injury, and adverse HCW mental health outcomes. Hospitals with shared governance models, which promote participatory decision making in health care and elevate workers’ voices in workplace matters, have lower rates of burnout and higher job satisfaction ratings from nurses, plus improved quality of care and patient outcomes (Spence Laschinger & Leiter, 2006; Kutney-Lee et al., 2015). Adequate nurse staffing levels – especially when mandated – are recognized as a critical factor to improving accountability and the work environment, and have yielded positive outcomes for patients and HCWs alike, including quality of care and retention (Aiken et al., 2010; McHugh et al., 2021; Buchan, Catton & Shaffer, 2022; American Federation of Teachers, undated). Reducing the burden of administrative and clerical requirements on HCWs can improve job satisfaction and decrease burnout (DeChant et al., 2019). Medical scribes perform real-time documentation of clinical encounters, allowing HCWs to spend less time on paperwork and more time listening to patients. Multiple reviews find that the use of medical scribes is associated with improved clinician satisfaction and patient experience, and decreased levels of burnout (DeChant et al., 2019; Ziemann, Erikson & Krips, 2021).

Structural barriers in seeking psychosocial support should be addressed and solutions tailored to different worker populations

Reliance on individual-level interventions fails to acknowledge structural barriers that some workers face when seeking help. For example, medical licensure boards in most of the United States ask questions about a history of mental illness. Such policies may deter applicants from seeking licences, stigmatize mental illness and prevent help-seeking behaviour (Jones et al., 2018).

Perhaps unsurprisingly then, a recent survey of primary care providers across 10 countries found that, despite very high levels of stress, emotional distress and burnout reported by respondents, a slim minority sought professional help, even when it was available (Stephenson, 2022). Confidential services delivered through digital interventions may therefore be especially valuable, as they can be accessed with less fear of losing jobs or being stigmatized.

Further, despite evidence on the various inequalities in the distribution of mental health burden among the HCWF, and the relationship between HCW age, psychological outcomes and burnout, the strategies described in the literature that aim to mitigate these outcomes are largely ‘one-size-fits-all’ and fail to account for the variations in worker demographics. For example, evidence of gender inequality during the pandemic shows that women experienced large declines in labour force participation globally, and those who remained in the HCWF experienced deteriorating working conditions, with evidence to suggest they have faced higher rates of burnout and mental health conditions, including depression, anxiety and PTSD (OECD, 2021e; Seedat & Rondon, 2021; Jefferson et al., 2022).

Many countries addressed the competing professional and domestic duties of HCWs, especially among women, by implementing supportive childcare measures

Childcare was a pressing need during the pandemic when most schools and childcare facilities closed to the public. This need was especially strong for women, who make up 67% of the global HCWF, and who are also disproportionately responsible for childcare (OECD, 2020e) (Box 8). In many countries (e.g., Austria, France, Germany and the Netherlands), emergency measures were enacted to keep facilities open for the provision of childcare for essential workers, including HCWs (Williams, 2020a). In some countries, financial support to help with childcare costs was provided to parents through vouchers or paid subsidies (e.g., Italy) (Ricci et al., 2020), by offering paid time off to care for children (e.g., France, Portugal), or by subsidizing the cost for employers who provide it (e.g., Japan) (OECD, 2020e).

Box 8

Women played a prodigious role in the COVID-19 response yet were overlooked in policies.

Countries also implemented strategies to facilitate transportation for HCWs and provide them with safe accommodation in which to isolate

Transportation needs of HCWs were also addressed by many countries through providing them with free public transport (e.g., Hungary), free access to public cycling schemes (London, United Kingdom) and parking (e.g., Finland) (Williams et al., 2020a). Countries also provided free lodging to health workers, often in hotels close to the hospitals in which they worked, enabling HCWs to isolate from their families in safe accommodation, so as not to risk spreading COVID-19 to their loved ones (Hou et al., 2020; Williams et al., 2020a). In Poland, for example, regional branches of the National Health Fund were responsible for securing and paying for accommodation for HCWs treating COVID-19 patients (Williams et al., 2020a).

Additional pay and bonuses were implemented in many countries to support and incentivize HCWs

Many countries (including 18 across Europe, Canada, nine French- and Portuguese-speaking West African countries, and more) provided increased financial support to HCWs in the first year of the pandemic, usually in the form of one-time or monthly bonuses (Williams et al., 2020a). In some countries, bonus amounts were a flat rate, while in others, it varied based on profession (e.g., Kyrgyzstan), base salary (e.g., Greece), and severity of the pandemic (e.g., France). In South American countries, such as Columbia and Chile, salary adjustments were awarded by region to attract HCWs to areas experiencing HCWF shortages (WHO, 2021b). In most cases, bonuses were issued on behalf of the national government, although in countries like Armenia and Estonia, individual hospitals paid bonuses. In Germany, bonuses issued by states were granted on top of that provided by the national government (Williams et al., 2020a). In the United States, the federal government passed multiple items of legislation to provide financial support for the health care system and HCWs. Specifically, legislation provided billions of dollars in loans to HCWs to support the sustainability of their practices, compensate for financial losses due to the pandemic, increase and expand provider reimbursements for COVID-19 patient care and telehealth services, and to support rural HCWs and stabilize the direct care workforce (O’Malley Watts, Musumeci & Chidambaram, 2020; Ochieng et al., 2022).

Long-term care workers, long underpaid and undervalued, were at the epicentre of the COVID-19 pandemic, and many countries issued them financial incentives and hazard pay

The pandemic shone a spotlight on the chronic underinvestment and systemic discrimination faced by LTC workers, as well as their critical role in national health care systems (Box 9). In an attempt to stabilize and strengthen this workforce, countries like Germany, France and the United States provided increased financial support for LTC workers in the form of salary increases and bonuses (Scales & McCall, 2022; OECD, 2021c). In countries including Czechia and the Republic of Korea, wages for LTC workers were permanently increased (OECD, 2021c). In the United States, federal legislation provided states with a significant infusion of one-time funds earmarked for ‘home and community-based services’ for the elderly and disabled, which many used to provide wage increases and bonuses to LTC workers (O’Malley Watts, Musumeci & Chidambaram, 2020).

Box 9

The COVID-19 pandemic highlighted the systemic challenges and hazards LTC workers face, but also elevated their prioritization in policy responses.

The provision of childcare support may alleviate a significant stressor in the lives of HCWs, especially women

Many HCWs are affected by the social determinants of health (Seeholzer et al., 2022). Among these is access to childcare, which has been identified as a significant stressor for health workers – particularly women (OECD, 2020e; Harry et al., 2022). Childcare stress has been associated with increased odds of experiencing anxiety, depression and burnout (Harry et al., 2022), which in turn adversely affect worker retention and patient quality of care (Murthy, 2022). It is reasonable to posit then that programmes to address childcare challenges, such as those implemented as emergency measures during the pandemic, could alleviate HCW childcare stress and its impact on workers, patients and health systems. Furthermore, evidence suggests a positive return on investment for providing childcare for health workers; a simulation study in the United States found that in nearly every county in the country, it would be less expensive to provide childcare to all health workers with children than to absorb the costs of HCW absenteeism during school closures (Chin et al., 2020).

Practical support measures like HCW accommodation may improve worker well-being and facilitate care delivery

There is little literature examining the effectiveness of other practical support strategies implemented by countries in response to the pandemic. However, the fear of infecting a loved one during pandemics or other outbreaks has been identified as a risk factor for adverse psychological outcomes in HCWs and a deterrent to participation in emergency response efforts (Abdul Rahim et al., 2022; Buchan, Catton & Shaffer, 2022; Santinha, Forte & Gomes, 2022). Therefore, the provision of safe accommodation, where HCWs can isolate away from their families during disease outbreaks, may alleviate one of the psychological stressors they face and remove a barrier to HCW emergency response. There is also some evidence from China and Italy that, when infection prevention protocols (e.g., temperature screening, meal delivery, separate elevators) are put in place, such accommodation can successfully house HCWs without contributing to the spread of disease (Hou et al., 2020; Vimercati et al., 2020).

Additional payments reduced personal financial challenges among HCWs but this does not mean that the general pay conditions have been addressed

The provision of additional financial payments does yield positive outcomes for workers, in terms of their economic well-being, retention and mental health. Analyses of United States hazard pay policies during COVID-19 find significant increases in wages and weekly earnings, and improved overall economic well-being for HCWs (Scales & McCall, 2022; SEIU 775 & Center for American Progress, undated). Increased payments also improved the ability of HCWs to keep up with rent and utility payments, and decreased their food insecurity. This link between increased worker pay and well-being is well-supported by the broader evidence base. Studies demonstrate that increasing compensation for low-wage HCWs, like many LTC workers, would lift hundreds of thousands of them and their children out of poverty, significantly reduce reliance on public assistance, and increase retirement savings and home ownership rates among this workforce (Himmelstein & Venkataramani, 2019; Weller et al., 2020). Furthermore, increasing wages has been shown to improve the physical and mental health of low-wage workers (Shook et al., 2020). There is also evidence that higher wages contribute to LTC workers’ intent to stay in their job (SEIU 775 & Center for American Progress, undated) as well as contributing positively to the mental health of HCWs by reducing worry, anxiety or depression about finances (SEIU 775 & Center for American Progress, undated).

There is also some evidence that national workforce investments during COVID-19 supported delivery of services. The provision of hazard pay for HCWs was identified as a contributing factor in promoting continuity of health services in Ethiopia during the pandemic (Arsenault et al., 2022), while government financial support in the United States allowed health care providers to maintain or improve their financial performance and operations (Binkowski, 2021).

Overall, the positive links between adequate financial compensation and HCW mental health, well-being and retention demonstrate the need to address pay and general conditions of the HCWF in many countries to maintain the current workforce (see the companion policy brief ‘What steps can improve and promote investment in the health and care workforce?’ in this series). However, increasing pay will not be sufficient for improving retention. A systematic review examining the relationship between the United Kingdom’s NHS workforce and satisfaction, retention and wages found that increased wages may improve retention by increasing job satisfaction, but without addressing other organizational and environmental factors, wages alone were limited in their ability to retain workers (Bimpong et al., 2020).