Health workforce: The health workforce crisis (2024)

The chronic shortage is well recognized as one of the main obstacles to delivery of effective health services to those who need them most. It is one of the most fundamental constraints to achieving international health and development goals such as theMillennium Development Goals and universal access to HIV prevention, treatment, care and support.

For populations, the impact is a lack of access to essential health services: prevention, information, drug distribution, emergencies, clinical care and life-saving interventions such as childhood immunization, safe pregnancy and delivery services formothers and access to treatment for AIDS, tuberculosis and malaria.

For health workers, the effect is an overwhelming workload and stress,, which can lead to a lack of motivation, fatigue, absenteeism, breakdowns, illness, migration or even a career change outside of the health field.

All countries are affected, one way or another -- the health worker crisis is an issue for everyone. Sub-Saharan Africa faces the greatest challenge and proportionately, is the most heavily affected region of the world. One million health workers are needed to bridge the gap in this region. While it has 25 % of the global burden of disease, it has only 3 % of the world's health workers. There are a cluster of countries in Southern Africa that are undergoing a deep crisis: few health workers, high HIV/AIDS, malaria and TB burden, poorly performing health systems, and the highest rate of migration anywhere in the world, particularly in that region's English-speaking countries.

Due to its considerable share of the world's population, Asia also needs millions of additional health workers to bridge its health workforce gap. The needs are greatest in South Asia, especially in rural areas.

In the European or North American media, the 'shortage' of health workers is also often discussed in relation to OECD countries. As populations (and the health workers themselves) are ageing in these countries, health care demand is constantly increasing.

Table: "Inequities in the distribution of health workers worldwide" (WHO 2006)

The current discourse on HRH is evolving from an exclusive focus on availability of health workers – i.e. numbers – towards accordingequal importance to accessibility, acceptability, quality and performance.

• Availability– the sufficient supply and appropriate stock of health workers, with the competencies and skill‐mix to match the health needs of the population;
• Accessibility– the equitable distribution of these health workers taking into account the demographic composition, rural‐urban mix and under‐served areas or populations;
• Acceptability– health workforce characteristics and ability (e.g. sex, language, culture, age, etc.)to treat all patients with dignity, create trust and promote demand for services;
• Quality– health workforce competencies, skills, knowledge and behaviour, as assessed according to professional norms and as perceived by users.

Without sufficient availability – accessibility to health workers cannot be guaranteed; if they are available and accessible, without acceptability, the health services might not be used, when the quality of the health workforce is inadequate, improvementsin health outcomes will not be satisfactory.

The 22.8/10,000 population threshold was identified in 2006 to partly illustrate the global shortage of health workers in relation to the objective of delivering essential health services of relevance to the MDGs – primarily MDG 4 and 5. The HRH‘crisis’ category refers to two dimensions: density of skilled health professionals less than 22.8/10,000 population and deliveries by skilled birth attendants less than 80%; so low HRH density and low service coverage together. Usingthis threshold the WHR 2006 identified a shortage of 4.3 million health workers.

Almost a decade later, the threshold of 34.5 skilled health professionals (midwives, nurses and physicians) per 10,000 population has emerged in the discourse on universal health coverage, based on the density of health professionals of a country (Thailand)which has attained very high coverage of a broader range of health services. This threshold comes from analysis conducted by the International Labour Organization in support of its regulation on Social Protection, the World Social Security Statistics2010/2011. There are currently 100 countries with a density of skilled health professionals below this threshold,translating in a total shortage of about 7.2 millionskilled health professionals.

Based on projections of a simple model entirely driven by population growth, thisgap would increase to 12.9 million by 2035.

It is important to note that none of these thresholds are meant to be planning targets, but rather are used to illustrate the variance in HRH availability, and the magnitude of challenges that lie ahead, calling for transformative approaches to planning,education and management of the health workforce.

Thresholds identified to allow comparisons and promote dialogue at global level however have limitations in terms of their use to national policy makers. What is needed is a move towards context-specific identification of needs and opportunities, so thatcountries can rather set their own benchmarks, assess progress, and revise them over time as required and as they broaden the scope of health services they intend to provide to the population.

When a country has a fragile health system, the loss of its workforce has the potential to bring the whole system to collapse, with significant consequences in terms of lives lost. From a financial perspective, when significant numbers of doctors andnurses leave, the countries that financed their education lose a return on their investment and become unwilling donors to the wealthy countries to which their health personnel have migrated.

Developing countries lose some of their most valuable health workers to richer countries. For example, 75 percent of doctors trained in Mozambique now work abroad. The majority work in Portugal (1,218) and the rest work in South Africa (61), US (20) andUK (16).*

* Human Resources for Health: New data on African Health professionals abroad.
Michael A. Clemens & Gunilla Pettersson

The issue is not about 'stopping' migration; rather it is about management and regulation. Freedom of movement is a fundamental right according to the 1948 Universal Declaration of Human Rights, and migration is a staple of human history. Globalizationhas accelerated this trend significantly. But the grave effects of health workforce migration on developing countries call for a responsible, regulated management of migration, with a critical aim that all countries move towards self-sufficiency.

Some countries specifically train health workers for 'export'. Bilateral agreements between 'importing' and 'exporting' countries need to be encouraged to protect the rights of the health worker and offer some guarantee of employment level in the 'importing'country.

The Alliance and several of its partners, in particular WHO, is also working on a Global Code of Practice on ethical international recruitment of health workers. This instrument will be designed to ensure that all best practices are followed and protectthe rights of workers while providing a framework for bilateral cooperation.

Health systems are not easily or rapidly strengthened or reformed. Scaling up 'production' (educating and training more health workers) is the initial stage but this can take time: a nursing qualification usually takes three years of training, and a physicianat least five. Innovative methods (distance learning, 'task shifting' or community health worker programmes) can shorten this delay effect, but there is no "quick fix" to this problem: community health workers, nurses and physicians need each otherto work effectively as teams.

More schools and teachers are also needed to really 'scale up', although technical advances (distance learning, IT) and increased twinning between schools can and should be used to enable this surge of students. Significant financial support and technicalcooperation are also necessary for improving a decaying infrastructure, as well as institutional development for improving the quality of education.

The next step is employment, which brings challenges of its own: many countries affected by the health worker shortage already have scores of unemployed health workers: public spending on health may be capped (due to macroeconomic constraints), and privateenterprise may not be an option for individual health workers. Many countries thus lack the capacity to employ the workforce they have trained.

If nothing is done, the crisis will worsen. If action is taken – as recommended by WHO, The Alliance and many field experts – with strong country ownership and leadership, stakeholder consultation, national and international funding, the crisiscould be at least partially solved by 2015, thereby enabling the fulfilment of the health-related Millennium Development Goals.

The Alliance is a global partnership, formed in 2006 as a joint platform for action on the health workforce crisis. Its members include governments, UN agencies, professional associations, NGOs, foundations, research and training institutions and theprivate sector. When the scale and complexity of the health workforce issue became apparent, so did the need for a global focal point which could assemble all these actors' interest around a common goal: to ensure that all people have access to askilled, motivated and supported health worker.

As a partnership, The Alliance' purpose is to highlight the crisis and keep it on the global agenda, convene members, partners and countries to work together to find solutions, advocate for their effective implementation and facilitate the sharing ofknowledge and best practices on health workforce issues.

For administrative and legal purposes, The Alliance Secretariat is housed within the headquarters of the World Health Organization (WHO) in Geneva, Switzerland. WHO does not fund nor control The Alliance' operations, but is a founding member and partnerof The Alliance with a permanent seat on the Board of The Alliance, as are professional associations, NGOs and other constituencies including donor governments.

Health Workforce (HWF), WHO Headquarters (HQ)