The role of government chief nursing and midwifery officers in addressing the social determinants of health inequalities in the WHO European region

Abstract

Health inequalities continue to exacerbate in the European Region, this underlines the need to strengthen the equity impact of public health policies. Nurses and midwives, professional groups that account for 61.8% of the practicing health professionals, work at the point of care, interdisciplinary and see the effects of health inequalities in their everyday work supporting communities and the environment where they are born, live, work and age. The government chief nursing and midwifery officer (GCNMOs) influence, provide policy advice and lead health systems planning and delivery of services. Further to this, it is increasingly being document that they participate in public health policy and inspire others to commit to the implementation of a new vision to strengthen equity impact on population health outcomes. In 2023, a series of discussions with GCNMOs, multidisciplinary researchers and experts, representing 35 of 53 countries in the WHO European Region explored the implications as to how GCNMOs can contribute to addressing the social determinants of health inequalities. Based on this dialogue, we provide a proposal of public health actions for health equity that will benefit from GCNMOs in delivering co-benefits for better health and inclusive growth. These actions can include equity-responsive health systems and health promotion, universal social protection, secure employment and healthy working conditions, environmental protection, education, decent housing, or urban planning among others. Unless governments facilitate the process where GCNMOs have clear mandates, sufficient authority, recognition, and support to engage in policy advocacy, governments will miss out on building fairer and healthier societies that are truly intersectoral and collaborative.

Health inequalities continue to challenge the European Region and have been recently exacerbated by the war in Ukraine, the effects of climate change, the COVID-19 pandemic, fiscal constraints, and what continues to be a long-standing concurrence of noncommunicable disease and emerging infectious diseases [1]. The need to strengthen the equity impact of the public health policies and respond to the apparent “permacrisis” now facing the WHO European Region cannot be resolved by narrowed-focus policies.

Nurses and midwives at the point of care advocate every day for their patients, work interdisciplinary, connect families and patients with community resources, but most important they see the impact of the health inequalities in their everyday work as they support individuals and communities to achieve their physical, mental, and social health and wellbeing potential in the environment in which they are born, live, work and age. This critical contribution at the point of care, considering nurses and midwives in the WHO European Region, account for 61.8% of the practicing health professionals, [2] is also reflected at the policy level. This is why in response to the World Health Assembly adopted resolution 74.15 that calls Member States to “establish and strengthen national and subnational senior leadership roles for nurses and midwives with authority and responsibility for management of nursing and midwifery workforces and input into health decision-making” and “consider appointing government chief nursing and midwifery officers (GCNMOs)”, [3, 4] the WHO Regional Office for Europe called on Member States to nominate a government nursing and/or midwifery officer (GCNMO) [5]. A call that only half of the region’s Member States were able to meet. The absence of influence and expert nursing and midwifery knowledge at the policy level, represents a missed opportunity to ensuring regulation of these professions working conditions and education, [6] and timely action towards the improvement of population health a core of nursing and midwifery foundation from the point of care to the policy level [7]. Furthermore, they are a majority women, representing another missed opportunity to strengthen female representation. Harnessing the leadership and field expertise of nursing and midwifery professionals in the design and implementation of public policies with a broader vision of society and setting the foundations to deliberate action required to redress systemic gender inequalities, also within the health and care work, [8, 9] making inroads on achieving universal health coverage and the 2030 sustainable development goals.

Previous literature on nurses’ role in addressing the social determinants of health inequalities tend to focus on nurses’ education, immediate actions at the point of care or the advocacy role nurses can have in their position at academia, nursing associations, or other related fields, overlooking nurses’ role at the government level [10,11,12,13]. In this context, a series of online discussions were conducted with GCNMOs, multidisciplinary researchers and experts representing 35 countries of the WHO European Region, including from European Union, Eastern Europe, and Central Asia. The discussions explored the implications as to how GCNMOs can and do contribute to addressing the social determinants of health inequalities. This article is framed by the WHO’s policy brief on the nursing policy leadership models in the WHO European Region [5] and it delineates main areas to stimulate further research in nursing and midwifery in addressing the social determinants of health inequalities.

The GCNMOs “assist the government to achieve the health goals of the country through nursing and midwifery, by provision of expert advice based on timely accurate local data and national and international evidence, and through professional networks of influence and professional understanding” [14]. Their roles can be categorized under three main areas. First, influence, including providing strategic direction, establishing liaison, collaboration and networking and advocating for population’s health in public health policies. Second, policy advise to government and participate to the health agenda setting. In addition to influence and policy advise, GCNMOs also can have a role linked to health systems planning and delivery of services [14].

In the WHO European Region, there are a diversity of nursing policy leadership models [5]—i.e. executive, advisor, programme, dispersal and focal point that vary from country to country. For example, according to the dominant model in the country, Ireland [15] and Israel [16] appointed a director of nursing that has line authority over the nursing and midwifery workforces and shapes health policy, this can be defined as executive model; the Netherlands is an example of advisory model, they appointed a nursing advisor who is engaged in national decision-making and external to the government; the programme model can be illustrated by Lithuania that appointed a nurse to manage primary health care; the dispersal model is illustrated by Iceland that positions multiple nurses and midwives as expert advisors to senior policy-makers of the Ministry of Health structure; and a focal point model is Latvia that nominated a nurse to engage in nursing and midwifery international meetings and forums on behalf of the government.

The work of GCNMOs is often interdisciplinary and trans-sectoral and that a considerable proportion of their work regularly involves working with educators, professional associations, and trade unions, but also between ministries, including ministries of social affairs, education, labour or finances [5]. This has also been an important lever in responding to the devastating epidemiological, economic and social effects of the COVID-19 pandemic. At the policy level, several GCNMOs during the COVID-19 pandemic participated in drafting, reviewing and/or updating legislation on the nursing and midwifery professions and regulation of education institutions; developing clear strategic plans to address lack of personnel; planning and managing health services, including quality assurance; promoting staff safety and well-being; coordinating between levels, including between municipalities and various levels of government, and supporting intersectoral coordination through involvement in mass vaccination programmes; strengthening collaboration with professional associations, multiple providers, unions and education institutions; and contributing to data collection to inform policy development [5].

Long-standing evidence-based strategies are available to tackle health inequalities and the impact of health policies and non-health-sector policies in the health of populations [17, 18]. Currently, in the WHO European Region 23 (43%) countries have national and/or subnational policies addressing the reduction of health inequalities established and documented [19]. Rosa et al. in 2021 published a report [20] on nurses’ action for health equity where six domains are highlighted for nurses to act on the social determinants of health mainly at the point of care, including, education and training; monitoring and evaluation; working with individuals and communities; healthcare organizations as employers, managers and commissioners; working in partnership within the health sector and beyond; and, nurses as advocates [20]. Table 1 describes upstream public health actions for health equity that add to the ones previously described. These are areas that will benefit from the presence of a GCNMO in addressing social determinants of health inequalities, adding to these areas that have been traditionally the mandate of GCNMOs, i.e. nursing and midwifery workforces and equity-responsive health systems, including health promotion [5, 14, 21].

Table 1 Areas that would benefit from the presence of GCNMOs

In moving forward, there are several elements that should be considered at the individual, systems and structural level.

The development of individual leadership competencies and intellectual, interpersonal and communication skills are key in developing a nursing policy leadership role. However, the policy leadership competencies are directly linked to the access of nurses and midwives to policy leadership courses and programmes for senior nurses, clear career structure and pathways and mentorship support. In making sure there are equal opportunities for women and men to access policy leadership programmes and mentorship, countries need to acknowledge and take action on the barriers that prevent women from reaching them, recognizing that women’s disadvantage intersects with and is multiplied by other identities, such as race and class [9].

The lack of programmes for leadership preparation and policy literacy both during initial training and later in their careers have been documented as a major barrier for nurses and midwives to take senior policy leadership roles [22, 23]. The GCNMOs positions are influenced by many factors, some of them can be the policy agenda of the country or the strength of organized nursing and midwifery associations. This is also in line to what has been previously described in the literature [24]. Barriers to access health governance and policy activities also include: lack of financial resources; lack of political will; lack of legality; fundamental flaws in the policy ideas; and, governability and disagreement [25]. In addition, other hindering factors to access senior policy leadership positions in a given country are linked to the historical process and roles of the nursing and midwifery professions, the relationship with the medical profession and its degree of public recognition. In turn, these elements are influenced by the position of women in society and their access to educational and senior positions in the health, social and political systems, as well as the degree to which the professions have been able to organize as a collective body with agreed aims and plans [9].

GCNMOs are transformational leaders able to influence on public health policy and inspire others to commit to the implementation of a new vision to strengthen equity impact on population health outcomes, they can join forces with other sectors to deliver on equity-responsive health systems, universal social protection, secure employment and healthy working conditions, environmental protection, education, decent housing, or urban planning among others. For this, however, more governments will need to facilitate the process where GCNMOs have clear mandates, sufficient authority, recognition, and support to engage in policy advocacy and working collaboratively and inter-sectoral towards building fairer and healthier societies.