Health worker shortage could derail development goals



Clare Nullis-Kapp

Cape Town



Senior government and development officials gathered in the Nigerian capital Abuja agreed urgent action was needed to tackle a growing shortage of doctors, nurses and other health workers.

They warned this could undermine global efforts to cut poverty and disease.

The High-Level Forum meeting on the health Millennium Development Goals, on 2–3 December, focused on strengthening health systems and ways to increase the volume, coordination and efficacy of aid to achieve the goals. Officials agreed that solving the crisis in human resources was key to advancing their development agenda.

"When aid is unpredictable, we cannot blame planners in our countries for being overcautious," said Nigerian Health Minister Eyitayo Lambo. "We simply cannot commit to hiring new doctors and nurses or to putting more people on treatment for AIDS if resources suddenly dry up."

"We understand donors need reassurance that their money is well spent. But governments also need freedom to set priorities," the minister said.

An action agenda submitted to the meeting called for more global solidarity, for example that industrialized countries adopt an ethical approach to recruiting health workers from developing countries.

Under the slogan: Train, Retain and Sustain, it called on African countries to improve training, compensation and working conditions of health professionals.

The agenda also urged governments to learn from the lessons of countries, such as Argentina, Brazil and Iran, on a number of workforce-related issues, for example: recruitment best practices for training and retaining a sufficient number of health workers.

Ministries of labour, finance and education — and not just health — should be involved in health workforce issues. Governments should seize the political momentum created by the Millennium Development Goals to promote their health and development agenda, it said.

There are an estimated 750 000 health workers for a population of 682 million people in Africa: 10–15 times lower than in OECD (Organisation for Economic Co-operation and Development) countries, according to two reports prepared for the Forum: Addressing Africa's Health Workforce Crisis: an Avenue for Action and Health Workforce Challenges: Lessons from Country Experiences.



The region accounts for only 1.3% of the world's health workforce but 25% of global burden of disease.

To achieve the Millennium Development Goals, the minimum level of health workforce density is estimated at 2.5 health workers per 1000 people compared with the current average of 0.8 health workers. Only six unnamed African countries currently have the minimum workforce capacity, according to the meeting documents.

"If we want a noticeable improvement in reducing maternal mortality rates and improving child health, then we have to have a higher density of health workers," Kerstin Leitner, WHO Assistant Director-General for Sustainable Development and Healthy Environments, told the Bulletin.

Africa will require an estimated one million additional health workers to ensure the staffing required to deliver basic health interventions.

The two reports identified four key "hot buttons" responsible for the chronic shortage.

• Insufficient training opportunities. Two-thirds of sub-Saharan African countries have only one medical school, and eleven have no medical schools at all. There is too much emphasis on highly skilled personnel rather than other health workers.

• Deteriorating health of the workforce. In many sub-Saharan African countries between 18% and 41% of the workforce is already infected with HIV. In Zambia and Malawi, death of nurses represents almost 40% of the annual output from training, whereas in Ghana there has been no noticeable increase in the health worker death rate.

• Rural/urban imbalance. In the United Republic of Tanzania, the city of Dar es Salaam alone has nearly 30 times as many medical officers and medical specialists as other rural districts. Only about five of Uganda's 100 or so surgeons work outside urban areas.

• The "brain drain" of health professionals from poor developing countries like Ghana, Kenya, Malawi and Zimbabwe to higher-income developing countries such as South Africa and Botswana, and then on to richer countries such as Australia, Canada, New Zealand, the United Kingdom and the United States. An estimated 18 000 Zimbabwean nurses work abroad, whilst more Malawian doctors reportedly practise in the northern English city of Manchester than in all of Malawi.

At the same time, it is estimated that a further one million nurses will be needed over the next 10 years to meet the shortfall in the United States. By 2008, the United Kingdom will need 25 000 doctors and 250 000 nurses more than it did in 1997, and other industrialized nations predict similar shortfalls. Bilateral agreements to regulate the movement of health workers have so far had limited impact.

Leitner described the shortages as "staggering", especially given the relatively high unemployment levels in some OECD countries.

She said there was a role for WHO in advising governments how to manage the migration.

"In terms of movement of people it is a good thing to have health personnel with international experience, but this should not lead to a net reduction of health personnel in developing countries," Leitner said. "At the moment it is a one way ticket."

World Health Organization Genebra - Genebra - Switzerland