The Five-Year Action Plan for Health Employment and Inclusive Economic Growth from the World Health Organization, International Labour Organization, and the Organisation for Economic Co-operation and Development was recently adopted. It was developed from the Global Strategy on Human Resources for Health: Workforce 2030. [1,2] Together, the global strategy and the action plan address issues around the uneven distribution of health workers and severe shortages globally. While the action plan highlights the positive economic benefits of investing in human resources for health (HRH), it largely fails to address the economic constraints to implementing it. 
The strategy forecasts the creation of 40 million additional jobs to meet the global “demand” by 2030—but mainly in high and middle income countries. Demand is based on the country’s domestic capacity to fund such jobs and implies only 0.5 million of these extra jobs will be generated in Africa, to meet their total demand of 2.4 million workers. However, calculations based on SDG norms (4.45 professional health workers/1000 inhabitants) indicate that 7.6 million health workers will be needed in Africa in 2030. Benchmarks based on an ability to pay maintain fundamental inequities in target setting and hide the widening mismatch between HRH needs and availability.
Several of the action plan’s recommendations refer to increasing health workers through increased investment in training and “life long learning.” While laudable, it is not enough. Although the shortage of health workers can in part be addressed through increased and improved supply, experience suggests that significant numbers of existing trained workers cannot enter the public health sector due to limited finances and fiscal space to absorb and remunerate them adequately in the public payroll. 
A large part of the health workforce in many poor countries is not on the official payroll. In Sierra Leone, 9350 health workers—approximately half of the professional health workforce—are unpaid volunteers, often waiting years to be recruited in the public sector. A similar situation exists in Guinea and in Mozambique, where over the past eight years thousands of health professionals waited to be included in the Ministry of Health payroll. [5,6] The renewed interest in task-shifting to community health workers overlooks the need to go beyond unpaid volunteers and improve their supervision, support, and career development; they too face inadequate remuneration and poor working conditions. 
The systematic underfunding of health workers in the public health system also leads to downstream financial barriers to patient access through staff’s dependence on patient fees.  The health system in Guinea largely relies on patients’ out-of-pocket payments to complement low state salaries or payment to “volunteers.” In Sierra Leone patient payments demanded by these volunteers undermine the application of the Free Health Care Initiative.  Furthermore, because patients are more likely to be able to pay in larger cities, this reinforces the uneven urban-rural distribution of health staff.
While the action plan highlights important problems, it fails to address critical points related to who will finance the recommended plans. The global strategy asserts that domestic resources for HRH “should be supported by appropriate macroeconomic policies at national and global levels” and that at least in certain circumstances “countries will require overseas development assistance for a few more decades to ensure adequate fiscal space” (part 38). Still, the action plan and the global strategy specify neither the criteria to assess such needs for continued international support, nor do they recommend measures to lift fiscal space limitations.
As international aid for health continues to flat-line or decrease, the current international aid discourse expects expanding health services to rely mainly on increases of domestic funding, even in resource limited settings. However, such reliance on domestic funding remains unrealistic in most countries and will stall progress towards the SDGs. In Lesotho, where international donors previously supported approximately 500 (lay) counsellors, in 2012 over half stopped working due to a reduction of funding and a lack of government capacity to absorb this funding cut. It negatively impacted on HIV testing programmes.  Similarly, HIV testing rates in Kwazulu Natal, South Africa, dropped by at least 25% when the government phased out the lay counsellor cadre in 2015. 
Countries struggling to address health challenges need sustained international support and targeted measures to address underlying inequities in the global health workforce distribution.
How do we ensure the effort to create HRH jobs and economic opportunities includes public health benefits for people affected by ill health in low resource contexts? While welcoming the global momentum towards investing in the health workforce, we fail to see how the action plan as it stands could drive the intended changes in public health. The improvement and expansion of training cannot translate into expansion of public services for those who need it most unless we ensure that health workers are absorbed into the public sector. If not, such workers may simply expand the private sector or boost the international brain drain.
To achieve increased access to free, quality services that advance the health status of everyone, including those most in need, WHO and other global health actors need to address the elephant in the room. Otherwise health workforce ambitions risk being trampled.
Originally published in the opinion pages of the British Medical Journal.
 OECD, ILO and WHO (2017) Five-Year Action Plan of the High-Level Commission on Health Employment and Economic Growth. Geneva.
 WHO (2016). Global Strategy on Human Resources for Health: Workforce 2030. World Health Organisation: Geneva.
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 Witter, S; Wurie, H; Bertone, MP (2015) The free health care initiative: how has it affected health workers in Sierra Leone? Health policy and planning. ISSN 0268-1080 DOI: 10.1093/heapol/czv006. Downloaded from: http://researchonline.lshtm.ac.uk/2137768.
 Bemelmans M, Goux D, Baert S, van Cutsem G, Motsamai M, Philips M, van Damme W, Mwale H, Biot M, van den Akker T. The uncertain future of lay counsellors: continuation of HIV services in Lesotho under pressure. Health Policy and Planning 2015, 1-8.
 Presentation MSF Eshowe project, IAS Durban 2016
 DFID (2010). Evaluation of the Malawi’s Emergency Human Resources Programme. Cambridge, USA: Management Sciences for Health. http://www.who.int/workforcealliance/media/news/2010/Malawi_MSH_MSC_EHRP_Final.pdf
 MSF (2016). HRH Assessment Malawi – internal report. Brussels, Belgium: Analysis and Advocacy Unit, Medecins Sans Frontieres.