Why the workforce is important
In this first decade of the 21st century, immense advances in human well-being coexist with extreme deprivation. In global health we are witnessing the benefits of new medicines and technologies. But there are unprecedented reversals. Life expectancies have collapsed in some of the poorest countries to half the level of the richest – attributable to the ravages of HIV/AIDS in parts of sub-Saharan Africa and to more than a dozen “failed states”. These setbacks have been accompanied by growing fears, in rich and poor countries alike, of new infectious threats such as SARS and avian influenza and “hidden” behavioural conditions such as mental disorders and domestic violence.
The world community has sufficient financial resources and technologies to tackle most of these health challenges; yet today many national health systems are weak, unresponsive, inequitable – even unsafe. What is needed now is political will to implement national plans, together with international cooperation to align resources, harness knowledge and build robust health systems for treating and preventing disease and promoting population health. Developing capable, motivated and supported health workers is essential for overcoming bottlenecks to achieve national and global health goals. Health care is a labour-intensive service industry. Health service providers are the personification of a system’s core values – they heal and care for people, ease pain and suffering, prevent disease and mitigate risk – the human link that connects knowledge to health action.
At the heart of each and every health system, the workforce is central to advancing health. There is ample evidence that worker numbers and quality are positively associated with immunization coverage, outreach of primary care, and infant, child and maternal survival (see Figure 1). The quality of doctors and the density of their distribution have been shown to correlate with positive outcomes in cardiovascular diseases. Conversely, child malnutrition has worsened with staff cutbacks during health sector reform. Cutting-edge quality improvements of health care are best initiated by workers themselves because they are in the unique position of identifying opportunities for innovation. In health systems, workers function as gatekeepers and navigators for the effective, or wasteful, application of all other resources such as drugs, vaccines and supplies.
Picture of the global workforce
All of us at some stage work for health – a mother caring for her child, a son escorting his parents to a hospital, or a healer drawing on ancient wisdom to offer care and solace. This report considers that “Health workers are all people primarily engaged in actions with the primary intent of enhancing health”. This is consistent with the WHO definition of health systems as comprising all activities with the primary goal of improving health – inclusive of family caregivers, patient–provider partners, parttime workers (especially women), health volunteers and community workers.
Based on new analyses of national censuses, labour surveys and statistical sources, WHO estimates there to be a total of 59.2 million full-time paid health workers worldwide (see Table 1). These workers are in health enterprises whose primary role is to improve health (such as health programmes operated by government or nongovernmental organizations) plus additional health workers in non-health organizations (such as nurses staffing a company or school clinic). Health service providers constitute about two thirds of the global health workforce, while the remaining third is composed of health management and support workers.
Workers are not just individuals but are integral parts of functioning health teams in which each member contributes different skills and performs different functions. Countries demonstrate enormous diversity in the skill mix of health teams. The ratio of nurses to doctors ranges from nearly 8:1 in the African Region to 1.5:1 in the Western Pacific Region. Among countries, there are approximately four nurses per doctor in Canada and the United States of America, while Chile, Peru, El Salvador and Mexico have fewer than one nurse per doctor. The spectrum of essential worker competencies is characterized by imbalances as seen, for example, in the dire shortage of public health specialists and health care managers in many countries. Typically, more than 70% of doctors are male while more than 70% of nurses are female – a marked gender imbalance. About two thirds of the workers are in the public sector and one third in the private sector.
Driving forces: past and future
Workers in health systems around the world are experiencing increasing stress and insecurity as they react to a complex array of forces – some old, some new (see Figure 2). Demographic and epidemiological transitions drive changes in population- based health threats to which the workforce must respond. Financing policies, technological advances and consumer expectations can dramatically shift demands on the workforce in health systems. Workers seek opportunities and job security in dynamic health labour markets that are part of the global political economy.
The spreading HIV/AIDS epidemic imposes huge work burdens, risks and threats. In many countries, health sector reform under structural adjustment capped public sector employment and limited investment in health worker education, thus drying up the supply of young graduates. Expanding labour markets have intensified professional concentration in urban areas and accelerated international migration from the poorest to the wealthiest countries. The consequent workforce crisis in many of the poorest countries is characterized by severe shortages, inappropriate skill mixes, and gaps in service coverage.
WHO has identified a threshold in workforce density below which high coverage of essential interventions, including those necessary to meet the health-related Millennium Development Goals (MDGs), is very unlikely (see Figure 3). Based on these estimates, there are currently 57 countries with critical shortages equivalent to a global deficit of 2.4 million doctors, nurses and midwives. The proportional shortfalls are greatest in sub-Saharan Africa, although numerical deficits are very large in South-East Asia because of its population size. Paradoxically, these insufficiencies often coexist in a country with large numbers of unemployed health professionals. Poverty, imperfect private labour markets, lack of public funds, bureaucratic red tape and political interference produce this paradox of shortages in the midst of underutilized talent.
Skill mix and distributional imbalances compound today’s problems. In many countries, the skills of limited yet expensive professionals are not well matched to the local profile of health needs. Critical skills in public health and health policy and management are often in deficit. Many workers face daunting working environments – poverty-level wages, unsupportive management, insufficient social recognition, and weak career development. Almost all countries suffer from maldistribution characterized by urban concentration and rural deficits, but these imbalances are perhaps most disturbing from a regional perspective. The WHO Region of the Americas, with 10% of the global burden of disease, has 37% of the world’s health workers spending more than 50% of the world’s health financing, whereas the African Region has 24% of the burden but only 3% of health workers commanding less than 1% of world health expenditure. The exodus of skilled professionals in the midst of so much unmet health need places Africa at the epicentre of the global health workforce crisis.
This crisis has the potential to deepen in the coming years. Demand for service providers will escalate markedly in all countries – rich and poor. Richer countries face a future of low fertility and large populations of elderly people, which will cause a shift towards chronic and degenerative diseases with high care demands. Technological advances and income growth will require a more specialized workforce even as needs for basic care increase because of families’ declining capacity or willingness to care for their elderly members. Without massively increasing training of workers in this and other wealthy countries, these growing gaps will exert even greater pressure on the outflow of health workers from poorer regions.
In poorer countries, large cohorts of young people (1 billion adolescents) will join an increasingly ageing population, both groups rapidly urbanizing. Many of these countries are dealing with unfinished agendas of infectious disease and the rapid emergence of chronic illness complicated by the magnitude of the HIV/AIDS epidemic. The availability of effective vaccines and drugs to cope with these health threats imposes huge practical and moral imperatives to respond effectively. The chasm is widening between what can be done and what is happening on the ground. Success in bridging this gap will be determined in large measure by how well the workforce is developed for effective health systems.
These challenges, past and future, are well illustrated by considering how the workforce must be mobilized to address specific health challenges.
- The MDGs target the major poverty-linked diseases devastating poor populations, focusing on maternal and child health care and the control of HIV/AIDS, tuberculosis and malaria. Countries that are experiencing the greatest difficulties in meeting the MDGs, many in sub-Saharan Africa, face absolute shortfalls in their health workforce. Major challenges exist in bringing priority disease programmes into line with primary care provision, deploying workers equitably for universal access to HIV/AIDS treatment, scaling up delegation to community workers, and creating public health strategies for disease prevention.
- Chronic diseases, consisting of cardiovascular and metabolic diseases, cancers, injuries, and neurological and psychological disorders, are major burdens affecting rich and poor populations alike. New paradigms of care are driving a shift from acute tertiary hospital care to patient-centred, home-based and team-driven care requiring new skills, disciplinary collaboration and continuity of care – as demonstrated by innovative approaches in Europe and North America. Risk reduction, moreover, depends on measures to protect the environment and the modification of lifestyle factors such as diet, smoking and exercise through behaviour change.
- Health crises of epidemics, natural disasters and conflict are sudden, often unexpected, but invariably recurring. Meeting the challenges requires coordinated planning based on sound information, rapid mobilization of workers, commandand- control responses, and intersectoral collaboration with nongovernmental organizations, the military, peacekeepers and the media. Specialized workforce capacities are needed for the surveillance of epidemics or for the reconstruction of societies torn apart by ethnic conflict. The quality of response, ultimately, depends upon workforce preparedness based on local capacity backed by timely international support.
These examples illustrate the enormous richness and diversity of the workforce needed to tackle specific health problems. The tasks and functions required are extraordinarily demanding, and each must be integrated into coherent national health systems. All of the problems necessitate efforts beyond the health sector. Effective strategies therefore require all relevant actors and organizations to work together.