Comparing Health Workforce Policy during a Major Global Health Crisis: A Critical Conceptual Debate and International Empirical Investigation
2.1. Theoretical Background: Aligning Health Workforce Research and Comparative Health Policy
- Organizational studies highlight the operational dimensions of governance and leadership issues, including the role of professional actors . The concept of “street level bureaucrats” is another useful framework for comparison, which highlights the connectedness of professions and organizations ;
- Comparative health policy may explore institutional conditions and macro-level policy developments. There is no common approach to cross-country comparison and existing typologies are highly diverse, yet most authors refer to three basic categories, including governance (or regulation, in previous classification schemes), finance, and the provision of healthcare (for an overview, see  (pp. 6–14)).
2.2. Introducing a Conceptual Approach for Comparative Health Workforce Research
2.3. Gathering and Analyzing the Material
3.1. A Quantitative Descriptive Health System-Based Approach: Comparing Brazil, Canada, Germany, and Italy
3.2. An Explorative Qualitative Case Study Design: Comparing Health Workforce Governance and COVID-19 Policy in Context across Countries
3.3. A Cross-Country Comparative Overview of Major Results
|Health policy responses to COVID-19||Denial of the pandemic in Brazil (under past President Bolsonaro) with action taken mainly at a local/community level; strong lockdown and social distancing policies in Italy, more moderate in Germany and Canada; access to vaccination (in Brazil only after pressure on Bolsonaro government) and some financial support to mitigate the effects in all countries, strongest in Germany.|
|Public health sector and hospital sector||Well-established and experienced public health sector in Brazil, similar in Canada and Italy, but weak in Germany; the hospital sector shows the opposite picture with a very strong position in Germany and weaker in Brazil, Canada, and Italy.|
|Health workforce and workplace conditions||High levels of death of HCWs, in particular nurses, poor PPE and training support in Brazil; lower risk of death and better PPE protection in Germany and Canada; more mixed in Italy with poor protection especially during the first wave. |
Staffing levels and HCWF composition vary strongly, with Brazil placed at a comparably lower and Germany at upper levels and Italy and Canada in-between. However, workplace stress worsened, shortages were an important problem in all countries, policy attention was overall poor, and effective solutions were lacking.
|Individual actors, mental health conditions||Poor mental health of HCWs; lack of attention especially during the first waves of the pandemic; overall poor mental health support in all countries.|
|Gender equality, the situation of women HCWs||Lack of attention to gender equality and the needs of women HCWs; especially nurses, who were hit most severely; exacerbation of social inequalities.|
|The situation of migrant HCWs||Lack of attention to migrant HCWs and their needs; exacerbation of social inequalities.|
- Health policy research must pay greater attention to health workforce policy and healthcare workers. Our comparative research investigation has illustrated the benefits of an integrated governance approach and a country case-study design based on various categories beyond health system typologies;
- Similar health workforce problems across countries highlight essential problems of pandemic policy and politics that may threaten HCWs and health system resilience. There is an urgent need for health policy to respond more effectively to the needs of individual HCWs and prevent gender, racial, and other inequalities during a major global health crisis.
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
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|Substance of Governance||Assessment Categories|
|Unified health system (SUS) with free access to health services, federative coordination, and responsibilities devolved to government and municipalities.||Beveridge-type health system, decentralized federalism with most responsibilities devolved to provinces and territories.||Social Health Insurance (SHI) system, joint SHI self-administration, decentralized, federalist, responsibilities devolved to states, communities, and corporatist actors.||National Health Service (NHS) system, decentralized, responsibilities for management of healthcare services devolved to regions.|
|Finance||Funded by taxes, with mandatory contribution of 15–22% of municipal, state and federal budgets.||Funded mainly by income tax payments; 70% public, 30% private financing.||Funded mainly by employer and employee contributions with additional tax and private sources.||Funded mainly by taxes; about 75% public, 25% private financing.|
|Total health expenditure, all providers, %GDP *||9.6||11.78||12.8||9.5|
|Provision||Public and universal provision; additional voluntary private health insurance available.||Public provision of medical and hospital care; private mix for long term care, re-adaptation, and dental care.||Public provision with private mix (strong in long-term care), but joint SHI regulation||Public provision with significant private mix in hospital and outpatient care.|
|Hospital beds per 1000 population *||2.47||2.55||7.82||3.19|
Total health and social employment density *
|Physician density *||2.15||2.77||4.53||4.13|
|Nurse density *||1.55 (7.43 #)||10.06||12.06||6.26|
|Professional carers |
Infection rate, % of population
|Death rate, % of cases||2.79||1.81||2.36||2.86|
|Vaccinated % of |
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Kuhlmann, E.; Denis, J.-L.; Côté, N.; Lotta, G.; Neri, S. Comparing Health Workforce Policy during a Major Global Health Crisis: A Critical Conceptual Debate and International Empirical Investigation. Int. J. Environ. Res. Public Health 2023, 20, 5035. https://doi.org/10.3390/ijerph20065035
Kuhlmann E, Denis J-L, Côté N, Lotta G, Neri S. Comparing Health Workforce Policy during a Major Global Health Crisis: A Critical Conceptual Debate and International Empirical Investigation. International Journal of Environmental Research and Public Health. 2023; 20(6):5035. https://doi.org/10.3390/ijerph20065035Chicago/Turabian Style
Kuhlmann, Ellen, Jean-Louis Denis, Nancy Côté, Gabriela Lotta, and Stefano Neri. 2023. "Comparing Health Workforce Policy during a Major Global Health Crisis: A Critical Conceptual Debate and International Empirical Investigation" International Journal of Environmental Research and Public Health 20, no. 6: 5035. https://doi.org/10.3390/ijerph20065035