By Sarah Boseley - guardian.co.uk
Africa is desperately short of doctors and nurses. So is much of Asia. In 57 countries, the situation is deemed by the World Health Organisation (WHO) to be at crisis point; they have fewer than 2.3 nurses, doctors and midwives for every 1,000 people – too few to deliver the basic level of care needed.
But in contrast to some other developing world problems, this is an issue that really does affect all of us. The world needs an estimated 4.2 million more health workers.
Though nowhere near crisis point, the USA and Europe are also seriously short of health workers. The problems of poor countries are therefore exacerbated by doctors and nurses from developing nations moving to find better jobs and a better quality of life, given the pressure, tough conditions and low pay they can expect in their home countries.
In its 2006 report, the WHO estimated that 23% of doctors trained in sub-Saharan Africa are working in economically developed OECD countries. Canada and the United States, with only 10% of the global burden of diseases, have 37% of the world's health workers.
Dr Mubashar Sheikh, executive director of the Global Health Workforce Alliance (GHWA), set up in 2006 to pull together national governments and other organisations interested in promoting health, says this is "a truly global crisis". Health workers move not only to wealthier nations, but also within their own countries, from the countryside to the towns, seeking better working conditions and pay.
"Mobility is a human right," says Sheikh. "You can't stop people from moving. Our argument is that people have a right to move, but access to health is a human right too. There has to be a balance."
Unless things can be improved, says Sheikh, there will be little chance of meeting the UN's health-related millennium development goals (MDGs) by 2015, but the scale of the problem is daunting.
Of the 57 crisis countries, 36 are in sub-Saharan Africa, which is struggling with the MDG targets of cutting child deaths and the numbers of women who die in childbirth. Africa, which bears 24% of the global burden of disease, has just 3% of the health workforce, according to the WHO. An estimated 1.5 million extra health workers are needed across the continent. According to a 2005 estimate, 334,000 skilled birth attendants would need to be trained globally just to reach 72% of annual births.
This is why the global health movement has been moving in recent years away from treating diseases such as HIV/Aids in isolation to support for "health systems" in general. Five million people with HIV in developing countries are now on drugs to keep them alive, but one survey estimated the treatment programmes took up the services of 20-50% of all health workers in two countries and 10% in a further 10. Today's thinking is that it makes no sense for a nurse to treat only HIV when the woman in front of her may have a child with pneumonia or a baby with life-threatening diarrhoea.
Improving health systems doesn't have to mean building smart hospitals, says Dr Sheikh. "We don't necessarily need fancy infrastructure," he says. The crucial part is well-trained and well-motivated people, who need to be able to access the drugs required and emergency care for patients. "There is a general consensus that health workers are the lifeline of the system." He includes not just the obvious doctor, nurse and midwife but also the lab technician, the theatre assistant, the researcher and the manager.
The global health workforce is now definitively on the agenda. In 2006, the WHO's annual report analysed the scope of the shortages and the way forward. For only the second time in the history of public health, WHO has now agreed a voluntary code – encouraging the training of health workers and attempting to place recruitment in an ethical framework. The last three G8 communiques recognised the crisis and committed to help poor countries. The US has pledged to support the training of 140,000 health workers, mostly in Africa, and Japan will support 100,000 more. Other countries including the UK have also made undertakings.
Most importantly, countries with shortages must find ways to train, motivate and retain more people. "Countries losing health workers need to give it top priority and keep the right environment and conditions which encourage health workers to stay within their own community," says Sheikh. It's not always about years of medical school – Ethiopia and Tanzania have made great strides by training large numbers of community health workers, who often do not want to move away.
Brian Rockliffe, the director of the charity VSO, says in his foreword to a report on health worker migration: "We believe that the sustainability of Africa's health systems, and the long-term effectiveness of international aid efforts to strengthen them, rests on finding a solution to the global mobility of Africa's health workforce."
The report, called Brain Gain: making health migration work for rich and poor countries, found that many health workers who had gone to work in richer countries would also, in fact, rather be at home. VSO talks of circular migration – making it attractive and possible for those who have left poor countries for Europe or the USA to return to a job that offers reasonable pay, without the stress involved in trying to treat too many people with too few drugs and inadequate equipment.
Fundamentally that means training more healthcare workers and finding more money to support them. If the MDGs are to be achieved and the global health worker shortage not to become still more acute, there is little alternative.
Read more about what AMREF does to train health workers.