The healthcare workforce shortage – a new pandemic
Vishal Venkat Raman writes on the pressing need to address the global healthworker shortfall.
The World Health Organisation (WHO) estimates there is a global shortage of 4.3 million healthcare workers, with sub-Saharan Africa and South-East Asia worst affected. They have 53% of the global disease burden but only 15% of the world’s healthcare workforce. In Ghana, for example, there are only 15 physicians per 100,000 population compared with 230 per 100,000 in the UK. (1) This drastically compromises the ability of these countries to provide adequate coverage rates of life-saving therapies like immunisations and deliveries by skilled birth attendants and it is essential to recognize this as one of the largest global health crises of the 21st century. Kofi Annan once said, “whether our task is fighting poverty, stemming the spread of disease or saving innocent lives from mass murder, we have seen that we cannot succeed without the leadership of the strong and the engagement of all.” Therefore, those of us in the developed world must do everything in our power to ensure a successful end to this pandemic.
Several factors have contributed to the marked shortages in these areas. One of the most important is that there are simply too few new health professionals being trained. Educational facilities are scarce; two-thirds of African countries have just one medical school while some have none at all. In addition, careers in the public health sector are becoming less attractive to graduates due to their low salaries and poor working conditions. (2) Local governments are unable to provide the funding required to alleviate such problems due to budget constraints resulting from years of poor economic growth.
A significant depletion of their public sector healthcare workforce has also occurred. Increased demand for health services in richer countries has provided the appropriate incentives to drain doctors and nurses away from sub-Saharan Africa and South East Asia. In Ghana, for example, 604 out of the 871 medical officers trained in the country between 1993 and 2002 now practice overseas. Similarly, only 360 of the 1200 doctors trained in Zimbabwe during the 1990s remain there today. (3) Most of these people have emigrated to the UK, USA, Canada and Australia, where 23 – 28% of all physicians are international graduates. (4) The recruitment activities of many foreign NGOs and donor funded aid projects, such as PEPFAR, have also drawn skilled labour away from national health services. These programs, which work outside local health systems, receive disease-specific grants and so have highly restricted agendas. This leaves a severely depleted public health network struggling to cope with all the other problems such as treating diarrhoeal diseases or providing maternal care.
So what can be done to resolve this crisis? Simply put, in the badly affected regions there must be an increase in the production of trained labour and a reduction in the haemorrhaging of staff away from where they are most needed.
A report by the Global Health Workforce Alliance has offered strategies to solve this problem. (5) It proposes that governments of the nations with critical shortages devise 10-year ‘scale-up’ plans to expand the education and training of all groups of healthcare workers. Importantly, it places a particular focus on huge increases in those in the community equipped with basic skills. The rationale is that by raising the number of community health workers, who can perform simple but essential functions such as distributing mosquito nets, a far greater positive impact can be achieved at a reduced cost.
It is estimated that an extra 1.5 million workers are needed in Africa alone, and the cost of training them will be $2.6 billion per year. (5) The economic burden of solving this crisis is clearly too great for local governments to cope with alone. Countries like the UK and USA, who have so richly benefited from the increased migration globalisation has brought, need to accept that they have a duty to help. Their governments should offer adequate financial assistance for such ‘scale-up’ efforts.
In addition to producing more trained staff, the right incentives need to be in place to encourage people to work for public health sectors and in the areas where they will have the greatest impact. (6) A combination of financial (such as higher wages, performance related bonuses) and non-financial incentives (such as flexible working hours, manageable workloads, supportive management) is necessary. To be effective they must be realistic, deliverable and contextually appropriate. More importantly they should reflect workers’ needs and wants. Establishing schemes that can stem the leak of human capital that has occurred will be difficult, but policies introduced in Ghana and Kenya have shown that these goals are achievable. (6)
Thomas Friedman told us the world is getting flatter and globalisation is rapidly empowering smaller organisations and individuals. (7) It is clear the impact this is having, with NGOs now more able to influence healthcare than ever before. This means, however, that these establishments should operate more thoughtfully, particularly with greater consideration for the country’s overall public health situation.
Only with a collaborative effort between state governments, various NGOs and international bodies, like the UN and WHO, will it be possible to engineer an effective cure for this crisis. This is the time for the UN and WHO to accept greater leadership in ensuring such co-operation occurs and for all governments to offer them the support they will require.
John F. Kennedy stated in his inaugural address, “to those people in the huts and villages of half the globe struggling to break the bonds of mass misery, we pledge our best efforts to help them help themselves – because it is right” and “if a free society cannot help the many who are poor, it cannot save the few who are rich.” These words still hold true today, and if we are to fulfil such a promise over the coming years we must help build sustainable healthcare systems in the countries that desperately need them. And when it comes to healthcare, its most important asset is the workforce.
Vishal Venkat Raman, 5th year medical student at the University of Oxford, UK.
vishal.venkatraman@oriel.ox.ac.uk
References
(1) World Health Organization. 2006. World health report 2006: working together for health. Geneva: WHO. http://www.who.int/whr/2006/en/
(2) High-Level forum on the health MDGs. 2004. Health workforce challenges: lessons from country experiences. http://www.hlfhealthmdgs.org/Documents/HealthWorkforceChallenges-Final.pdf
(3) Garrett L. The Challenge of Global Health. Foreign Affairs. January/February 2007.
(4) Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005; 353: 1810-1818.
(5) World Health Organisation. Global Health Workforce Alliance. 2008. Scaling up, Saving Lives. http://www.who.int/workforcealliance/documents/Global_Health%20FINAL%20REPORT.pdf
(6) World Health Organization. Global Health Workforce Alliance. 2008. Incentives for Health Professionals. http://www.who.int/workforcealliance/documents/Incentives_Guidelines%20EN.pdf
(7) Friedman TL. The World Is Flat – The Globalized World in the 21st Century. UK: Penguin Press; 2007.