Background
Health and care workers, the majority of whom are women, are central to attaining international and national health.1 2 Yet many countries still underinvest in their education and working conditions. The pivotal role of health and care workers during the COVID-19 pandemic, along with the health and psychological impacts they endured in the course of their work, has placed a spotlight on their needs: a renewed and sustained focus on their occupational health and safety; fair remuneration as part of decent working conditions; protection from harassment, workplace violence (which affects all health and care workers, but can be particularly harmful for women), stigma, and discrimination; an enabling work environment with needed resources to perform their roles and; addressing the growing burden of unpaid care work, especially for women, in the health and social care sectors.
Estimates suggest between 80 000 and 180 000 deaths globally among health and care workers due to COVID-19 between January 2020 and May 2021,3 with shortage of and inadequate personal protective equipment (PPE) recognised as a key contributing cause.4 Many health and care workers lacked access to testing, paid sick time, treatment, and COVID-19 vaccines—even as wealthier countries were vaccinating populations at far lower risk of contracting the virus.5 Health and care workers experienced mental health issues during COVID-19 due to a range of causes, from witnessing illness and death at significantly higher rates to experiencing bullying and harassment, and from working extended hours to worrying about their own higher exposure to the virus. They often lacked access to necessary services and support.6
Inadequate resources and staffing during the pandemic spurred collective action among health and care workers for safer working conditions.7 However, some workers were prevented from or penalised for organising,8 while others faced significant legal and practical obstacles.9 Of grave concern, some health workers were investigated, detained, and imprisoned for informing the public or other health workers of the scope of the spread of COVID-19,10 questioning or criticising their government’ response,11–13 and disputing official infection numbers.13 14
Violence against health and care workers increased during the COVID-19 pandemic, both in the workplace and in the community due to their occupation.15–17
While some of these fundamental workplace challenges have been exacerbated by the pandemic, they existed before. Often, health and care workers who experience workplace violence lack outlets to report it, or do not report it due to fear of retaliation.18
Violence against health workers is particularly rife during armed conflicts, with documentation of hundreds having been killed in conflict-affected areas19 as well as in other chronic complex emergencies.20 21
Health workers have also experienced human rights violations in conflict settings in retaliation against their acting in accordance with their professional and humanitarian ethics, such as providing care to anti-government protesters and other civilians.22 Providing impartial care to the sick and wounded on the battlefield is one of the foundations of the Geneva Conventions and has been a humanitarian norm since the mid-19th century. National counterterrorism laws increasingly have been used to prosecute health workers for performing their duties impartially. In at least 10 of 16 countries that have such laws that one study surveyed, counterterrorism legislation has been interpreted to include providing medical care as a form of supporting terrorists.23 24
Further, health and care workers face gender-based violence and harassment and other forms of discrimination in the workplace. Though comprising 67% of the global health and care workforce, women hold only 25% of senior roles25 and perform the majority (76%) of unpaid care work.9 Migrant and ethnic-minority nurses are at higher risk of work-related discrimination than native or ethnic-majority nurses, and discrimination is a leading cause of impaired health among these workers.9
Compensation is one area where gender inequality surfaces: Using weighted global estimates, the gender pay gap in the health and care sector ranges from about 15% (in the case of median hourly wages) to about 24% (in the case of mean monthly earnings), and men are over-represented in higher-paid occupations.26 More than one-third of the gender pay gap cannot be explained by different working hours and occupational categories.27 28 It has been estimated that women contribute US$3–US$4.5 trillion annually to global health, one-third to one-half through unpaid care work.27 29 Community health workers, disproportionately women, are frequently underpaid or unpaid.9 30
Health and care workers face other compensation inequities. As a human capital-intensive sector, health and care has an over-representation of low-paid workers.28 This includes low wages in the long-term care sector, particularly for personal carers. In Organisation for Economic Co-operation and Development (OECD) countries, pay is 35% lower in the long-term care sector than the hospital sector for workers in the same occupation.31 Young and newly qualified health and care workers often must perform unpaid or underpaid work during their education and early career.32 During the COVID-19 pandemic, students were asked to temporarily delay their education to take on unpaid or underpaid and undersupervised roles.
Health and care workers often lack social protections, especially those working in private homes and those in part-time or temporary work arrangements or with casual contracts.9 33 Lack of paid parental and family leave is a particular concern,34 while those providing unpaid care often lack access to social benefits more broadly.9 33 Furthermore, health and care workers frequently lack enabling work environments,9 35 while groups experiencing marginalisation, such as women and migrants, often occupy lower-level positions with little voice in decision-making, which may lead to lack of supportive work environments.36
In recognition of the unprecedented difficulties health and care workers faced during the pandemic, but also of the broader and longer-term nature of some of these challenges, the 74th World Health Assembly (WHA) in 2021 requested the WHO to develop, based on already existing normative documents of relevant international organisations (including WHO and International Labour Organization (ILO)), a global health and care worker compact providing guidance on how to ‘protect health and care workers and safeguard their rights, and to promote and ensure decent work, free from racial and all other forms of discrimination and a safe and enabling practice environment.’37 The 75th WHA in 2022 adopted a resolution calling on countries to ‘use, where relevant, the global health and care worker compact to inform national review, action and implementation to protect and support health and care workers.’38
This paper describes the approach and discusses the findings that led to the development of this compact, a milestone in the international health and care workforce policy domain.39 Importantly, the violations of the rights of health and care workers are anything but inevitable. From evidence-based recommendations from global organisations to policies and models from local to national levels—whether safe healthcare worker-to-patient staffing ratios, wide-ranging protections against discrimination and effective remedies, legal protections that are inclusive of often-excluded domestic care workers, or strong legal protections for whistle-blowers and unionisation, for example—effective, rights-respecting laws and policies exist, recommendations and models from which countries can learn, adapt, and implement.