Introduction   In May 2024, Africa took a historic step towards improving its health systems with the adoption of the Charter for Investment in Human Resources for Health . This instrument aims to address long-standing structural challenges, including chronic shortages of health personnel, poor resource allocation, and under-funding that compromise universal health coverage and health security. Such an initiative is in line with WHO's vision for Africa: to sustainably strengthen the continent's health systems and ensure accessible health care for all. Although this instrument is both ambitious and of great interest, we must ask ourselves what will become of it. Is there a risk that, like so many other initiatives adopted by African states in the past, it will be relegated to the sidelines and abandoned without any real implementation?     Context and purpose of the Charter   African healthcare systems face many challenges, including limited access to services and a lack of adequate funding to recruit, train and retain human resources in health. Although progress has been made, over 70% of African countries still face serious shortages. One in three health graduates is at risk of not finding a decent job after graduation. Current estimates indicate that the region will need between 5.3 and 6.1 million additional professionals by 2030 to meet the growing needs of the population. With an increase in health service coverage from 24% to 46% between 2000 and 2019, the continent remains far from the targets set to achieve universal health coverage (UHC) by 2030.     In fact, the unequal distribution of human resources in health, poor working conditions and the migration of qualified personnel are persistent challenges. While these problems exist worldwide, they are particularly acute in Africa. In many rural areas, primary healthcare facilities are severely understaffed and under-resourced. As we showed in a recent article, the retention of human resources in healthcare is particularly difficult due to poor working conditions, uncompetitive salaries and lack of career prospects. The lack of investment in this sector, combined with the low priority given to health, has exacerbated tensions in African healthcare systems. National resources allocated to health remain insufficient, preventing many countries from achieving UHC and guaranteeing health security. Indeed, 21 countries in the African region devote less than 5% of their gross domestic product (GDP) to health, while 36 countries spend less than the minimum US$112 per capita per year required to ensure access to essential health services. This situation has worsened with the pandemic, prompting many African countries to allocate more resources to debt repayment (Figure 1) rather than health spending, making it even more difficult to achieve health objectives.    

Figure 1: Debt service as a percentage of public expenditure in Africa

    The COVID-19 pandemic has also highlighted the crucial importance of human resources in ensuring not only public health, but also economic stability. As the Charter's preamble points out, "human resources in health represent a profitable investment for States and all investors. According to estimates by the International Labour Organization (ILO), increased spending to meet the health-related SDG targets would lead to the creation of around 173 million jobs worldwide in health and social work, as well as in other sectors. For every dollar invested in health and the creation of decent jobs for human resources in health, the potential return is around nine dollars. It has also been shown that half of the world's economic growth over the past decade has resulted from improved health, and that for every additional year of life expectancy, the rate of economic growth increases by 4%." (p. 7).     Faced with these challenges, increased investment in human resources for health is essential to stabilize and sustainably strengthen African healthcare systems. Unless substantial investments are made to recruit and retain these professionals in these areas, training efforts will be in vain, as many of these workers will leave for regions offering better conditions.     Charter framework   Before dwelling on the Charter's purpose and principles, let's briefly outline the process that led to its adoption. The development of this instrument followed a participatory process involving regional policy dialogues and consultations with key partners (Figure 2). This process, which began in November 2022 at a regional workshop in Accra (Ghana), saw the participation of 26 member states, as well as international organizations such as the ILO, the World Bank, USAID, the Global Fund and members of the Harmonization for Health in Africa (HHA) partnership, the Japan International Cooperation Agency (JICA), the Global Finance Facility (GFF), UNICEF, the African Development Bank (AfDB), the Frontline Health Workers Coalition and Africa Frontline First (AFF). An expert working group then met in Brazzaville in December 2022 to draft the charter, which was refined through several national and international consultations in 2023, before being adopted in 2024.    

Figure 2: Process for developing the Charter for investments in health human resources

Source:  Health human resources investment charter (p. VII)

    Objective   The aim of the Charter "is to align and stimulate investment in training, employment, retention and mobility of human resources for health, in order to halve inequalities in access to human resources for health, particularly in rural and primary health care settings, thereby creating decent jobs, especially for women and young people, strengthening health systems and accelerating progress towards universal health coverage, health security and the Sustainable Development Goals in Africa". It is based on five fundamental principles:   Principles  

1. State leadership and governance: Governments must play a central role in defining national priorities and coordinating investments. The Charter promotes the elevation of human resources for health issues to the highest level of national policy dialogue.
2. Evidence-based prioritization: Investments must be based on reliable data. The Charter encourages the collection and analysis of healthcare labor market data to guide decisions.
3. Investment alignment and synergy: Collaboration between governments, social partners and donors is essential to avoid wasting resources and maximize the impact of investments.
4. Stimulating investment: To offset historical under-investment, the Charter encourages increased financial resources devoted to human resources for health through national and international initiatives.
5. Sustainability of investments: The Charter promotes a long-term approach to investments in health human resources to ensure that current efforts benefit future generations.

  Theory of change   The theory of change lies at the heart of the Charter's development. It is based on an investment model guided by the five principles set out. Each stage of investment is closely linked to a process of governance and coordination between governments, social partners and financial players.   The implementation of investment actions begins with the identification of evidence-based priorities. This is followed by a dialogue between stakeholders to ensure that investments are aligned with the country's needs.

Figure 3: Theory of change

Source:  Health human resources investment charter (p.18)

  Once investments have been made, it is crucial to ensure their sustainability. To this end, the Charter provides for the establishment of an investment pact, formalizing the commitments of governments and investors.   Stakeholder commitments   The Member States, in collaboration with their partners, undertake to :

• Strengthen government leadership to coordinate investments.
• Improve data collection to ensure that investments in HRH are guided by sound evidence.
• Stimulate cross-sector investment to strengthen the link between health and other sectors such as education and economic development.
• Guarantee decent jobs and attractive working conditions for healthcare professionals.

  Follow-up and expected goals   Coordination and accountability mechanism   To ensure the follow-up and implementation of Charter commitments, a Consultative Committee on Investment in Human Resources for Health (CCIRHS) will be set up. This committee, headed by a health minister from one of the member states and co-chaired by a development partner, will meet annually to assess progress and guide future action. Monitoring indicators will include the number of countries that have adopted a multi-sectoral approach to investment in HRH, as well as the amount of funds mobilized for these investments.   Expected results   The Charter calls for ambitious results. These include the alignment of priorities between governments and development partners, the increased mobilization of funds, the reduction of inequalities in access to human resources for health, and the improvement of job quality for health workers.

1. Stakeholder alignment: All stakeholders (governments, social partners and financiers) must formalize their commitments in a national investment pact to ensure a coordinated approach.
2. Mobilizing funds: The aim is to increase funding to ensure decent working conditions for healthcare staff and meet priority health needs.
3. Equitable distribution of human resources: Particular attention will be paid to reducing inequalities, notably by increasing the number of professionals in rural areas and in primary healthcare.
4. Improving working conditions: The Charter seeks to improve the quality of employment in the healthcare sector, by strengthening workers' rights and promoting decent working conditions.

  Critical conclusion   Although the existence of such a Charter is to be welcomed, it is nevertheless legitimate to wonder, with some concern and reflected pessimism, about its real scope. What is the real value of an instrument that, despite the existence of monitoring and accountability mechanisms, is not legally binding on States? What compelling reasons exists to believe or hope that States will comply more fully with this Charter, in line with the principle of pacta sunt servanda (good faith) enshrined in Article 26 of the 1969 Vienna Convention on the Law of Treaties, especially when they have already failed to meet several of their commitments to improve the situation of human resources for health in Africa?     Indeed, these States have already failed to honor long-standing commitments, such as those enshrined in the African Union's Agenda 2063 (2013), the Addis Ababa Call to Action (2015), the Astana Declaration (2018), the WHO Global Strategy on Human Resources for Health to 2030 (2016), the Roadmap for Expanding the Health Workforce in the African Region 2012-2025 (2012), the West African Economic and Monetary Union (WAEMU) Action Plan (2018), the Southern African Development Community (SADC) Strategic Human Resources for Health Development Plan 2020-2030 (2020), the Global Compact on Human Resources for Health and Care (2022), the Working for Health 2022-2030 action plan (2022), the New Public Health Order (2022), and the Regional Strategy for Health Security and Emergencies 2022-2023 (2022).     As we often point out in our analyses, it will only be possible to achieve major advances in healthcare when African states fully integrate into their governance the idea that healthcare is not an expense, but a strategic investment. Such an awareness would be a decisive step towards improving health outcomes across the continent.