On 12 December 2012, the United Nations Assembly unanimously adopted a resolution committing member countries to Universal Health Coverage (UHC) and to give access to their population to health services of quality on the basis of need, and at acceptable costs. Some countries already do it, others have a long road to reach this objective. In Latin America, countries like Brazil, Colombia or Costa Rica among others have in place insurance schemes that cover most of the costs of health services. However, offering financial protection does not automatically give access to services of quality. Services corresponding to needs must be available at a reasonable distance and qualified health workers must be present, competent and motivated to produce care of quality.

Here reside the greatest challenges: how can a country attract, retain and motivate physicians, nurses and other professionals to regions where there are unmet needs? How to organize, in an effective and efficient manner, primary care and public health services which can address the vast majority of people's needs? Money does not do that; it is necessary but far from sufficient. Research shows that financial incentives alone do not attract health workers to difficult areas; non-financial incentives such as the availability of adequate infrastructure and equipment, of good supervision and of opportunities for professional development are just as important, in addition to personal support for housing, education of children or work of the spouse. Research also shows that teamwork, a skills-mix that makes the best use of the competencies of every member of the team, good communication and coordination within and between provider organizations, incentives consistent with service objectives, transparent mechanisms to monitor, assess and reward or sanction performance, feed-back and quality control, simple but relevant systems of information, all contribute to the production of services of quality.

All that precedes indicates that we know reasonably well what needs to be done to have a motivated workforce at the right place and to organize effective and efficient services. Why are we not doing it right? It is not a matter of financial resources, because the cost of these measures is much less than the costs of ineffective and inefficient services. If there is political commitment to move towards real UHC as there seems to be, the next most important ingredient in making UHC along these lines happen is good management of the health workforce and good management of services. In most countries, this is the missing link: policy-makers assume that it is enough to produce more professionals, though they do not always have a clear idea of which kind and how many are needed. They assume that paying more is enough to attract and retain qualified professionals outside urban areas. They pay little attention to the critical role which managers could play at the levels of provider organizations and of the definition of service delivery strategies. Managers need basic individual competencies which advanced education and experience can bring, but they also need an enabling organizational and institutional environment. By this, I refer to an access to a good information dashboard, to space to decide and to innovate, and to sufficient resources; of course the counterpart of managerial autonomy is managerial accountability. Investing in knowledgeable, experienced, and dedicated management is one of the main keys to progress towards quality health services for all.

Gilles Dussault
Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa

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