The price of the ticket

Ian Hodgson
6 April 2006

Educated and well-trained health workers save lives. This may seem obvious, but the truism packs a special punch on the day that the 2006 report of the World Health Organisation (WHO) cites evidence that large areas of the world – particularly in the global south – are grossly deficient in numbers of healthcare workers. The World Health Report says that immediate action is necessary if healthcare systems in the poor world are to have any chance of meeting their populations' needs. Why the deficiency, and what is to be done?

It is a fact of life that the areas of the world where health needs are greatest also have the least access to adequate health care. This "inverse care law" has plagued health systems for generations, but is currently reaching crisis proportion in many developing countries. The WHO estimates that there is a global shortage of four million skilled healthcare workers – doctors, nurses, midwives, dentists, pharmacists and support workers – with the lowest concentration being in sub-Saharan Africa. This is why, for World Health Day 2006, the WHO is focusing on the health workforce, and in particular the significant shortfalls in many non-OECD countries.

As the report says:

"A serious shortage of health workers in 57 countries is impairing provision of essential, life-saving interventions such as childhood immunization, safe pregnancy and delivery services for mothers, and access to treatment for HIV/AIDS, malaria and tuberculosis. This shortage, combined with a lack of training and knowledge, is also a major obstacle for health systems as they attempt to respond effectively to chronic diseases, avian influenza and other health challenges."

The figures are stark and self-evident. In sub-Saharan Africa, there are around 750,000 health workers in a region of 682 million people. For OECD countries, this figure is ten-to-fifteen times higher. There are simply not enough healthcare workers to go around; there may be a global average of 9.3 health workers per 1,000 people, but the difference between north America (41.7) and Africa (2.2) illustrates the inverse care law at its most insidious. Africa's estimated shortage of nearly 900,000 health workers means that the continent would require a 139% increase in order to address adequately its care needs.

The 2006 report emphasises the problem:

"At least 1.3 billion people worldwide lack access to the most basic healthcare, often because there is no health worker. The shortage is global, but the burden is greatest in countries overwhelmed by poverty and disease where these health workers are needed most. Shortages are most severe in sub-Saharan Africa, which has 11% of the world's population and 24% of the global burden of disease but only 3% of the world's health workers."

The brain-drain

The situation is exacerbated by a haemorrhaging of skilled practitioners away from poor countries to more prosperous nations. This is a major concern for the WHO and other agencies, such as the International Organisation of Migration which are especially concerned at the negative impact on "donor" countries of losing health workers.

Also by Ian Hodgson on openDemocracy:

"Loaded but lonely: the moralisation of US Aids policy"
(November 2005)

"Dazed and confused: the reality of Aids treatment in South Africa" (January 2006)

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The scale of the problem is significant. The WHO estimates that nearly 5% of nurses trained in sub-Saharan countries have migrated and are working in the world's seven richest countries. For individual countries the figure is higher – 13% in Ghana, for instance. Other studies provide similar evidence: in 2001, forty-seven nurses emigrated to the United Kingdom from Malawi – 20% of the total number trained that year. Between 1978 and 1999, 500 students in Zambia completed their medical training, but only around fifty are now left working in the country. Both Malawi and Zambia desperately need healthcare workers – they were placed at 165 and 166 (out of 177) in the 2005 United Nations Development Programme (UNDP) human development index.

The "push" factors explaining why health personnel choose to leave their home countries are evident: among them low salaries, poor facilities, lack of investment, and blocked career paths. A common though often underrated factor is job stress, particularly in countries seriously affected by HIV such as South Africa and Zimbabwe.

The "pull" factors attracting health workers to other countries are also clear: among them financial benefits, better training opportunities, safer working conditions, greater career prospects, and freedom from political and social turmoil. The higher wages health personnel can earn in richer countries often allow them send money back to their families. These "remittances" can make a significant impact on the GDP of countries with high numbers of migrants – 26.2% of Lesotho's, for example (see Chukwu Emeke-Chikezie, "African agency vs the aid industry", July 2005).

On one level, health-worker migration could be seen as a clear win-win situation. The worker benefits, and host countries, often with highly complex healthcare infrastructures, and burgeoning elderly populations requiring ever-higher levels of care, have a limitless source of employees in developing countries. There is also the advantage of a culturally mixed workforce, providing opportunities for sharing experiences and alternative insights into illness, disease and care. But – and this must be a huge caveat – damage to the health systems of home countries with a significant diaspora of skilled health workers is in some regions catastrophic.

What is to be done?

The situation is clearly complex and multi-layered. In principle, individuals should be free to pursue a career that suits their personal and professional development. They cannot be forced to stay in their home country – this would contravene basic human rights, as well as being unrealistic in the age of globalisation.

One solution would be to improve the working environment of health workers in their home countries, something that would improve recruitment and retention, and slow the "diaspora effect". This is the approach taken by the 2006 World Health Report, whose recommendations include stepping up education and training programmes, and protecting health workers by (for example) providing adequate resources to prevent occupational HIV transmission.

The World Health Report clearly aims to galvanise developing countries into improving the lot of their own health workers, and developed countries into mitigating their often rapacious tendency to poach health workers from poorer nations. Britain - in spite of an ethical code it signed up to in 1999 – continues to employ large numbers of nurses from developing countries: in one four-year period, as many as 6,000 migrated from South Africa into the British national health service.

World Health Day 2006 should be a moment for the WHO and other key stakeholders to address the issue of global inequity in health-worker provision in an integrated fashion, and find practical solutions. This will entail a willingness to face discomforting questions, of which the level, dynamic and impact of international migration is one.

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