Overcoming the health workforce gap

by Remco van de Pas, Linda Mans

The Chapter of Global Health Watch 4 on the global health workforce crisis tells us that the global deficit of health workers was estimated to be 4.2 million health workers in 2006. Due to population growth in Low-and Middle income countries and given the limited pace of development of the health workforce, at current levels, a global deficit of 12.9 skilled health professionals is projected for the year 2035. Under this assumption, 107 countries would be affected by this gap. The two regions where the absolute deficit would be the highest are South-East Asia (5.0 million) and Africa (4.3 million).

The current Ebola outbreak in Western-Africa is a telling reminder that weak health systems capacity, including the global deficit of the workforce, is an transnational challenge that requires a global response and approach which transcends national boundaries. For instance, Liberia had just 57 doctors and 978 nurses and midwives in 2008, while Sierra Leone had 136 doctors and 1017 nurses, far below WHO recommended staffing levels. This workforce deficit is one of the factors that contributed to the delayed containment of the Ebola outbreak and promoted transmission of the virus to urban areas – where it is much more difficult to control. Ironically, but not unexpectedly, a considerable proportion of the doctors and nurses that are nationals of the countries where the outbreak takes place, actually works in richer countries to earn an income with which they can sustain a family. It is estimated that 40% of Liberian doctors are currently working in the U.S alone.

In 2010 all Member States adopted, during the World Health Assembly, the WHO Global Code of Practice on the International Recruitment of Health Personnel – after skipping an article on compensation by destination countries to source countries of health workers. Currently, however, the UK-based civil society organization Health Poverty Action¹ is urging the Department for International Development (DFID) “for further clarification on how the UK government intends to compensate countries that are providing a subsidy to the NHS through their health workers.”²

Access to a skilled health worker should be considered part an essential part of the right to health as well as required to guarantee basic health protection. However, countries have not agreed upon an international framework that regulates a minimum level of available health workers for the population. Rather, international actors such as the World Bank and INGOs promote a labor market approach to scaling up the workforce. This would be hence not be a supply or needs driven model, but rather a demand driven model. Such an approach includes performance based finance models, cash transfers and insurance packages to boost demand of disadvantaged socio-economic groups. Many international donors and LMICs themselves propose task shifting to Community Health Workers (CHWs) or Extended Health Workers to provide basic services.

This supposedly 'cost-effective' and economic ‘utilitarian’ approach to health workforce development undermines the more intrinsic value that people have the right to access a skilled health worker, and that CHWs should be an integral part of the (continuum) of health care services. Now they are too often a poorly remunerated ‘lackey’ of the health service, rather than the ‘liberator’ (of the community’s potential).

The health workforce deficit is an absolute bottleneck to attain universal health care. Health workers are a scarce common good. Its absolute deficit requires considerable international attention and transnational public investments. One could for instance imagine a global health systems solidarity fund from which countries, that lack the essential number of skilled health workers, could request funds to finance education and deployment of health workers. This approach would not only serve basic rights, it will be beneficial at a global level to address (re)-emerging infectious diseases in an early stage, thus preventing possible global outbreaks. These health workers should receive fair remuneration, proper protection and healthy working conditions. Overcoming the health work force gap is one of the key system lessons we should learn from the current Ebola outbreak.