"Hanna Wafula lives in a small village in Zambia. She is 50 years old and lives with her husband and four grandchildren. Three of her six children have died: two when they were very young, and one last year at the age of 30. She notices that the doctor in the nearest health centre is rarely present. On the radio she heard that the government plans to spend more money on health care, but she has not seen any effects of increased spending yet. When she goes to the health facility, there is absolutely no guarantee there is a doctor or nurse to attend to her. The shortage of health personnel seriously impacts Hanna's life. Should she be in need of medical care there might not be a health worker available to treat her or her family." (1)
Human Resources for Health
Nurses and Doctors in a Globalized Context
by Linda Mans and Diana Hoeflake * **
The world is 7.2 million health workers short (2). Low-income countries are particularly affected by the shortage of health personnel (3). Too few health workers are being trained and retained due to insufficient public investments in health care and medical staff. Migration of health workers increases the inequalities and presents a challenge for all countries. Vacancies in high-income countries have a pull effect on qualified health workers from low- and middle-income countries. One of the reasons is that health personnel are leaving for greener pastures - countries where salaries are higher and facilities are better. Case in point, 57 per cent of all physicians trained in Zambia now work abroad, mainly in wealthier countries (4).
If the international recruitment is not carried out responsibly, it can have serious repercussions. When the much needed health workers are recruited from fragile health systems, those systems can be dangerously undermined. Equally, individuals who go to work in unfamiliar settings may be vulnerable to various forms of exploitation if no appropriate measures are taken. Allutis et.al. (2014) state that the health workforce crisis can be regarded as “one of the most pressing global health issues of our time (5)”. If nothing changes, the global health workforce shortage will reach 12.9 million in 2035 (6).
Europe is part of the problem. Various European countries recruit trained health personnel from abroad, a practice that is unsustainable, increases inequality and further weakens health systems in and outside Europe. In this context it is even more worrying that in the aging societies of European countries, the number of people who need long-term care is growing, thus fueling the demand for health workers. Forecasts indicate that, by 2020, Europe will need one to two million additional health workers (7). As the labour market becomes more globalized, rising demand is driving migration and mobility amongst health personnel.
Adequate measures are needed to prevent staff shortages anywhere in the world. In May 2010, the member states of the World Health Organization (WHO) adopted a global code of practice (WHO CoP) on the ethical recruitment of health workers (8). The WHO CoP encourages countries to solve their own (anticipating) shortages of health personnel in a sustainable and responsible manner. By adopting the code, member states agreed that they will be self-sufficient in the domestic health workforce deployment and that they will make sure that health systems in source countries are not undermined by international migration of health personnel. In addition, the WHO CoP calls for a fair and equal treatment of foreign health workers. By applying all the principles of the WHO CoP, countries become less dependent on foreign healthcare staff, and on a global and European scale they will subsequently pull away fewer health professionals.
Despite this code, political consensus on the sustainable management of health workforces and of health worker migration at the European level is still a long way off. There are powerful - albeit sometimes short-sighted - conflicting interests, and in many countries EU-driven austerity measures have put a damper on health expenditures and limit the implementation of policy options. Some countries attempted to lower expenditure through salary cuts or freezes and by reducing funds for training and retention purposes but these policies have exacerbated wage imbalances, thereby increasing health worker migration.
It’s therefore high time that all countries implement the principles of the WHO CoP. The Amsterdam-based advocacy organization Wemos calls on actors involved to abide by this code and advocates action towards achieving a sustainable health workforce and strengthening health systems. Wemos is member and coordinator of a European project entitled “Health workers for all and all for health workers” (HW4ALL). For the project, Wemos is working with civil society organizations (CSOs) in eight European countries: Belgium, the United Kingdom, Italy, Germany, Poland, Romania, Spain and the Netherlands. The project is designed to promote the responsible recruitment of health workers inside and outside the European Union. The CSOs are drawing attention to the consequences of the migration and mobility of health workers.
To ensure that everyone, anywhere in the world, has access to health workers, it is necessary that various ministries and other stakeholders, such as health care providers, work together on a sustainable future-oriented solution. Norway and Ireland are leading examples of WHO CoP implementation. They have implemented a sustainable national health care plan and experienced that this can only be achieved in cooperation with different ministries. For Ireland, the WHO CoP presents a particular challenge as this country employs relatively large numbers of nurses and doctors from outside Europe. Norway has been one of the trailblazers for the WHO CoP. Both countries have prioritized the creation of an effective registration system that can serve to signal areas in which shortages may arise. Additional effort is put into education and in-service training, partly with a view to increasing staff retention. Steps are also being taken to make careers in health care more attractive, such as by improving salaries. Where recruiting health workers from other countries is the only option, Norway and Ireland address the ethical aspects by making firm agreements with those countries. Furthermore, both Norway and Ireland provide aid to help them strengthen their health care systems. In doing so, globally sustainable and fair personnel policies can be ensured.
However, not solely destination countries but also the European Union (EU) can play an important role in contributing to fair and sustainable solutions for the health workforce crisis. In 2006, the EU stated that they “(…) will strive to make migration a positive factor for development, through the promotion of concrete measures aimed at reinforcing their contribution to poverty reduction, including facilitating remittances and limiting the âbrain drainâ of qualified people. (9)” However, for the global human resources for health crisis to be addressed instrumentally, greater coherence between migration, health, development, trade, education, labour, fiscal and other health workforce and migration related policies of the EU is needed. At European level there is a multitude of interventions and tools addressing the issue, making policy coherence a vital element in solving the health workforce crisis. Policy coherence helps create the proper context to ensure that gains for both the European health workforce, the rights of the individual health worker and the health systems in sources countries in and beyond Europe are maximized and costs - economic, social, human, administrative - are kept to a minimum.
Wemos, together with the other members of HW4ALL, strongly encourages a viable health workforce through long-term investment in education and training, accompanied by coherent planning and policies at local, national, and regional level. In doing so, we promote the use of the WHO CoP as a framework to regulate the pan-regional approach to human resources for health and to strengthen health systems not only in Europe but also globally. For example, we call on the EU and its member states to grant equal treatment and equal rights to migrant health workers, and ensure the full portability of social security and pension rights. In addition, we explicitly advocate the adoption of a policy coherence framework for developing sustainable health workforces in and outside Europe. Further, we among others highlight the currently limited possibility for European States to -take effective measures to educate, retain and sustain a health workforce that is appropriate for the specific conditions of each country- (as requested by the WHO CoP) in the context of austerity measures currently imposed on many of them.
We believe that everyone across the globe can have access to skilled health workers. Responsible and coherent policies for a sustainable health workforce will contribute to ensuring there are sufficient health providers available for everyone, everywhere. Then also Hanna and her family will receive health care whenever needed. That is why we advocate sustainable solutions for the global health workforce shortage!
Read more about the migration and mobility of health workers and the work of the HW4ALL project.
(2) World Health Organization. (2014). A Universal Truth: No Health Without a Workforce. Geneva: WHO Press.
(3) Sub- Saharan African countries suffer more than 24 per cent of the global disease burden, but have access to only three per cent of the worldâs health workforce. In Germany there are 34 doctors per 10,000 inhabitants available, whereas countries like Zambia and Kenya have to survive with only one.
(4) Ferrinho, H. et.al. (2011). The human resource for health situation in Zambia: deficit and mal distribution. Human Resources for Health. 9: 30.
(5) Aluttis, C. (2014). The workforce for health in a globalized context – global shortages and international migration. Global Health Action 7: 23611.
(6) World Health Organization. (2014). A Universal Truth: No Health Without a Workforce. Geneva: WHO Press.
(7) European Union (2012). COMMISSION STAFF WORKING DOCUMENT on an Action Plan for the EU Health Workforce. http://ec.europa.eu/dgs/health_consumer/docs/swd_ap_eu_healthcare_workforce_en.pdf
(8) WHO Code of Practice on the International Recruitment of Health Personnel: http://www.healthworkers4all.eu/fileadmin/docs/gb/WHO_Code_of_Practice.pdf
(9) See para. 38 of the European Consensus on Development, OJ C 46/01, 24.02.2006.
*Article republished from WEMOS November 20, 2014: http://www.wemos.nl/news/?v=2&lid=2&id=359&cid=3, with permission.
** Linda Mans is the project coordinator of the European consortium project “Health workers for all and all for health workers”, of which Wemos is the leading party. Together with partners from 8 European countries, this project aims to promote cohesion between development cooperation policies and domestic health policies and practices of European Member States and thus facilitating the establishment of responsible health worker policies. Through this project, Linda calls for more concerted action for better training, recruitment, retention and deployment of staff in the Netherlands and Europe. The WHO Global Code of Practice on the International Recruitment of Health Personnel World Health constitutes the starting point. Linda maintains relations with the Health Workforce Advocacy Initiative (HWAI) and the Global Health Workforce Alliance (GHWA).
Diana Hoeflake is responsible for Wemos’ social media. She writes articles for Wemos’ website and for trade media on health and international development. In addition, Diana carries out policy analyses and desk studies for the purpose of Wemos’ activities.