By Enrique Castro-Sanchez
ISID Emerging Leader
Research Lead (joint), Centre for Health Services Research
City, University of London, UK

This week the World Health Assembly meets once again [https://www.who.int/about/governance/world-health-assembly/seventy-fourth-world-health-assembly] to discuss progress on the most pressing health and care issues faced by nations and citizens around the world. Unsurprisingly perhaps, the response to the SARS-CoV-2 pandemic, including continued efforts to distribute the existing vaccines effectively and equitably, takes centre stage. But many other long-standing health topics remain in the working agenda, including drug-resistant infections and the chronic shortage of health care workers worldwide.

Robust studies in hospital and primary care settings worldwide have by now undoubtedly emphasised the crucial importance of an adequate health workforce, and the benefits of satisfactory staff/patient ratios to clinical outcomes, patient safety and experience, and organisational performance [McHugh MD Aiken LH Sloane DM Windsor C Douglas C Yates P. Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals.
Lancet. 2021; https://doi.org/10.1016/S0140-6736(21)00768-6]. Infection prevention and control and antimicrobial stewardship programmes and have also recognised the need to increase human resources in these areas.

For example, back in 2016, the O’Neill Report [https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf] advocated for the need to engage more healthcare workers in antimicrobial stewardship interventions.

This proposal seemed a good idea, and a logical and desirable ambition, perhaps underpinned by emerging opinions about the role that some professional groups traditionally absent from stewardship activities could play in support of them [Castro-Sánchez, E., Gilchrist, M., Ahmad, R. et al. Nurse roles in antimicrobial stewardship: lessons from public sectors models of acute care service delivery in the United Kingdom. Antimicrob Resist Infect Control 8, 162 (2019). https://doi.org/10.1186/s13756-019-0621-4]. However, few interventions seem to have been successful in increasing healthcare workers, although admittedly it may take years before the results of many of these initiatives come to fruition. Maintaining an adequate workforce is driven by complex, interconnected factors responsibility of different areas in governments [Fig from https://doi.org/10.1016/j.lanwpc.2020.100084].

It is not just about ensuring that enough university health graduates enter the job market, for example, but also guaranteeing that they remain there for as long as possible, which depends not only on salary but also wider working conditions, opportunities for professional development, progression, and recognition, existing team and organisational climates, and wider working-life balance policies, to name a few and which gain ever more prominence during traumatic collective events such as the current pandemic [Morgantini LA, Naha U, Wang H, Francavilla S, Acar Ö, Flores JM, et al. (2020) Factors contributing to healthcare professional burnout during the COVID-19 pandemic: A rapid turnaround global survey. PLoS ONE 15(9): e0238217. https://doi.org/10.1371/journal.pone.0238217].

There still an emphasis on improvement initiatives about education and training centred on the university educated, formal professions. Yet this perspective should be increasingly supplemented with interventions targeting other cadres which also provide care and engage in therapeutic decisions involving antibiotics, contribute to antibiotic management, or enable optimal health-seeking behaviours among patients and citizens and their self-efficacy related to infections and antibiotic use [Graham, K., Sinyangwe, C., Nicholas, S., King, R., Mukupa, S., Källander, K., Counihan, H., Montague, M., Tibenderana, J., & Hamade, P. (2016). Rational use of antibiotics by community health workers and caregivers for children with suspected pneumonia in Zambia: a cross-sectional mixed methods study. BMC public health, 16(1), 897. https://doi.org/10.1186/s12889-016-3541-8].

Additionally, the planetary threat of drug resistance should encourage us to adopt the widest perspective to the contribution that all health and social care workers can and should make. The emerging evidence about the weight of social determinants of health and illness and longstanding social inequities on clinical outcomes of persons with SARS-CoV-2 infection may serve as a powerful reminder about the influence of these same determinants on drug resistance [https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(18)30186-4/fulltext]. Moving away from a perception of antimicrobial stewardship centred around the better prescription of antibiotics, and embracing community stakeholders addressing the determinants of infection, may yield multiple benefits until the challenge of lacking health care workers is left to rest.