Health Workforce Shortage: A Global Crisis

There is a massive shortage of health workers globally but most intensely in developing countries. The dire shortage of health workers has considerably constrained achievement of health related millennium development goals. The reasons for shortage are multitude. Many countries in the world including developing countries as well as developed nations like UK and USA are not producing sufficient numbers of health workers. In developing countries like Sub-Saharan Africa, this is partly because of lack of medical school. Health workers are concentrated in urban areas and developed countries. Brain drain has devastating consequences in some of the donor countries. Substantial number of health workers leaves the health workforce prematurely. Population aging, increase in chronic diseases and conflicts are increasing the demand of health workforce. Efficient use of existing health workforce and task shifting are things that can be done as a short term response to this challenge whereas aggressive retention policies and increase in production of health workforce should be our long term strategies. Solving the problem of health workforce will require united effort of several national and international agencies. THE GLOBAL SHORTAGE IN HEALTH WORKFORCE Health workers are the cornerstone and drivers of health systems. And yet there is a massive global shortage of health workers.1 More than 59 million health workers are working worldwide, 4.3 million short of the total needed.1 This ongoing shortage is most intensely felt in countries that need them the most. For example, Sub-Saharan Africa bears more than 24% of the global burden of disease, but has access to only 3% of the world's health workers.1 In recent years, concerns about growing shortages of health professionals, in particular doctors and nurses, have emerged even in the most developed of nations.2 For example, in UK, the shortage of qualified medical staff is crippling the National Health Service.3 The dire shortage of health workers has considerably constrained achievement of health related millennium development goals.1 REASONS FOR SHORTAGE IN HEALTH WORKFORCE The reasons for shortage in health workforce are multitude including underproduction, maldistribution of health workforce, health workforce exit and increase in demand of health care. UNDERPRODUCTION OF HEALTH WORKFORCE Many countries in the world with acute shortage of health workforce face a lack of medical schools. For an instance, two thirds of sub-Saharan African countries have only one medical school and some have none.1, 4 In these areas, most medical schools are in disarray, are chronically under-funded, and academic research remains a luxury.5 On the other hand, the production of health workers is not sufficient even in countries like US, UK and Canada. 3, 6, 7 And these countries rely heavily on foreign health workers. This is evident by the fact that the International Medical Graduate comprises of 25 % of total physician population in the US. 8 HUMAN RESOURCE MALDISTRIBUTION AND MIGRATION Maldistribution between urban and rural areas is a huge problem nearly in all countries. For example, medical doctors and nurses in Bangladesh are concentrated in urban secondary and tertiary hospitals, while 70% of the population lives in rural areas.9 Even in a developed country like US, there is a drastic disparity in the percentage of Health Workforce Shortage: A Global Crisis 2 of 5 physician working in the rural areas.10 On top of this, migration of nurses and doctors to developed countries is crippling health systems in many poor sending-countries.11 By 2000, on average in the OECD countries, 11% of employed nurses and 18% of employed doctors were foreign-born. Caribbean countries and a number of African countries have particularly high emigration rates of doctors. For some of these countries this is combined with very low density of doctors in the home country, highlighting a very worrying situation for the health sector in these countries.2 Both push factors and pull factors are operating for this migration. The push factors include poor remuneration and facilities, limited career structures, poor intellectual stimulation, bad working conditions, the threat of violence, an oppressive political climate, persecution of intellectuals, and discrimination. Better remuneration, upgrading qualifications, gaining experience, a safer environment, family related matters are the important pull factors.12 HEALTH WORKFORCE EXIT Substantial number of health workers leaves the health workforce because of poor health, death and retirement while some workers leave temporarily in order to attend advanced courses.1 HEALTH HAZARD AND VIOLENCE AGAINST HEALTH WORKERS Increasing violence against health workers is prompting more and more health workers to quit their jobs.13 In Sweden, health sector is the occupation at the highest risk of violence.13 In the absence of appropriate safety guidelines, accidents and exposure to infectious diseases impose huge occupational threats. HIV/AIDS has rendered the health workplace a dangerous place in Sub-Saharan Africa. For example, from 1999 to 2005; Botswana lost 17% of its health workforce due to HIV/AIDS.1 REDUCTION IN DURATION OF SERVICE Many doctors especially young doctors are working fewer hours and pacing greater emphasis on personal time. 7, 14 Physicians are working significantly less in European Countries as a result of European Working Time Directive.15 Likewise in US, ACGME regulates the duty hours of medical residents to protect them from overwork and promote patient safety. 16 In Canada, large proportion of doctors now report that they want more time for themselves or their families. Further, in Canada, physician workforce has more elderly and female who work relatively less hours. 7 Also, earlier retirement trends are getting increasingly common among health workers in Canada. 7 In OECD countries, workforce ageing will decrease the supply of physicians as the “babyboom” generation of health workers reaches retirement age.2 INCREASE IN DEMAND OF HEALTH CARE Increased consumption of health care services, increase in chronic diseases and conflicts and emergence of new diseases are placing additional demands on a health workforce. Conflict often also causes severe and long-lasting damage to the health workforce itself.1 Population growth, ageing population and advancement in technologies are other factors increasing the demand of health workforce.2, 7 STRATEGIES TO DEAL WITH THE CURRENT CRISIS 1. Efficient use of the existing health workforce: Improving management and supervision, writing clear job descriptions, “piggy-backed” services (addition of services to pre-existing means of delivery), continued medical education and in-job training have been shown to improve the performance of the