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1 Search: your location : home > key issues > health systems > health care workers Share Health Systems The Importance Global View Health Care Workers Public Private Sector Interventions Health Care Workers Throughout history, periods of acceleration in health have been sparked by popular mobilization of workers in society. 1 Although there are an estimated 100 million health care workers worldwide, there is a projected shortage of more than 4 million workers.1 The World Health Organization (WHO) defines a health care worker (HCW) as anyone whose focus or activity is to improve health. This definition includes providers (e.g., doctors, nurses and midwives) as well as technicians and managers.2-4 Enter ... The nine categories of health care personnel are:5 1. Physicians 2. Nurses and Midwives 3. Dentists and dental assistants 4. Pharmacists 5. Laboratory scientists and technicians 6. Environment and public health workers 7. Community health workers and traditional healers 8. Other health care providers 9. Health managers and support workers Challenges of Health Care Workers Adequate health care provision depends on the availability of resources to retain health care workers and the availability of health care workers to manage the flow of those resources. In recent years, international donors and organizations have increased attention to funding for medical supplies, technology and management. However, the shortage of health care workers is a barrier in managing the flow of these resources.1, 3, 4, 6 In 15 countries in sub-saharan Africa, there are five or fewer physicians per 100,000 people below the recommended 20 physicians per 100,000. In 17 countries in sub-saharan Africa, there are 50 or fewer nurses per 100,000 people below the recommended 100 nurses per 100,000. Vaccination coverage is directly linked to the density of nurses and other health-related human resources and is almost entirely independent of physicians. Countries with less than 2.5 HCWs per 1,000 people were unable to provide 80% coverage for measles immunizations and deliveries by skilled birth attendants. Effective health care provision is an interdependent flow that is affected by many factors. Reasons for shortages and unbalanced skill gaps among the healthcare workforce are:6 Migration of health care workers within and between countries The growing demands of the HIV/AIDS epidemic Inadequate or ineffectual governmental policies and bureaucratic systems

2 Inadequate or ineffectual governmental policies and bureaucratic systems Lack of public resources Unregulated private labor markets Millennium Development Goals (MDGs) The health care worker shortage compromises the inability of many countries to meet the MDGs by weakening existing health care delivery systems. 7 Providing essential maternal and child health interventions is particularly dependent on trained health workers. Impact of Health Care Workers on Maternal, Child and Infant Survival 6 HIV/AIDS and Infectious Diseases Emerging high-priority situations, such as the increasing treatment and care of HIV/AIDS patients, require sufficient workforce mobilization without weakening the existing primary health care systems.1 In sub-saharan Africa, even though one medical assistant may treat as many as 200 HIV/AIDS patients per day, more than 70 percent of patients needing ARVs lack access to proper treatment. In some countries, the shortage of clinicians results in HIV patients waiting up to two months to start treatment. 8 In 17 countries with high prevalence of tuberculosis, staffing problems hindered disease control efforts and has reduced their likelihood of achieving the 2005 WHO targets. 4 Keys to Workforce Development All country programs for workforce development should include involving government leaders and financial contributors, preparing for and managing an increase in workforce through policies and investments, and evaluating performance of healthcare workers. Raising awareness among key stakeholders is a key component of workforce development, as are policies promoting and investments in health systems. Among the players who should be involved in this process are ministers of finance, health and education; academic leaders and educational institutions; professional associations and labor unions; and non-governmental organizations.1 The Global Health Workforce Alliance campaign is designed to combat health worker shortages and skill gaps. The campaign ensures that health workers have access to HIV prevention methods and funding for training and retention of health workers.9 Task Shifting 10 As defined by WHO, UNAIDS and the President s Emergency Plan for AIDS Relief (PEPFAR), task shifting is the decentralization of certain tasks to others with less overall medical training in

3 order to increase access to health care services despite the global shortage of health care workers. For example, specific tasks could be shifted from physicians to nurse practitioners and from nurses to community health workers. Task shifting includes realistically and responsibly shifting tasks to health care workers or others who are trained to deliver a specific set of services. Health care volunteers are also valuable for task shifting, but should not be relied upon for long-term sustainability. This approach evolved out of the need to destress highly strained professions, in particular those involved with HIV services. It is intended to be implemented based on a country s need for health care workers, while instituting appropriate training and certification for those workers. Adequate supervision, competency requirements, effective referral systems and patient empowerment are all important aspects of task shifting recommended by the WHO. Skill imbalances are a concern in some countries, such as China, where the number of physicians greatly exceeds the number of nurses. With an increasing elderly population, nurses play a critical role in geriatric care. 11 Task shifting can be used in this situation to increase geriatric services despite lower nurse density. Partners in Health, an organization working on health issues, describes task shifting as a cornerstone of [their] health care model, where community health workers will take on some physician responsibilities, among other duties. All staff in a task shifting position are financially compensated for their responsibilities. 12 While task shifting may be optimal in some situations, there are some potential risks. Some concerns of task shifting are:13, 14 Standardizing task shifting instead of creating a country or community-level specific program. Lack of program flexibility to change with community needs and technology. Blurring of health professional roles leading to untrained workers in high competency positions. Shortage or absence of health workers to train and supervise newly trained workers. Taking jobs from qualified health workers; task shifting is intended to alleviate shortages. Inefficient shifting of tasks that reduces quality of care and slows down health systems. Increased responsibilities for already overburdened lower-level health workers. Lack of sustainable task shifting programs due to worker burnout or inadequate funding. Internal Migration and Brain Drain Africa is home to nearly 25 percent of the global burden of disease, but only has 3 percent of the total global health workforce. In contrast, the Americas contain close to 40 percent of the total global health workforce, but only exhibit around 10 percent of the global burden of disease.6, 15 Global Disease Burden and Health Care Workforce 6, 15

4 Low-income to High-income Countries Fifty-seven of the world s poorest countries have a health care worker shortage of 2.4 million doctors, nurses and midwives. In Africa alone, there is a shortage of 1.5 million health care workers.6 Several high-income countries also face a shortage of health care workers. Health care workers from developing countries may leave their own countries to fill these positions, which provide better compensation and potential incentives. More than 25 percent of all doctors working in Canada, New Zealand, the United Kingdom and the United States have come from other countries; one in four physicians educated in Africa have left their home countries for a higherincome country.16 The Philippines is one of the world s largest exporters of health workers, making this one of the country s most important exports.17 Eight out of 10 Filipino physicians plan to pursue careers overseas, mainly as nurses, in developed countries where nurses receive higher pay than a public physician in the Philippines. Of Filipino nursing students, 60 percent are educated professionals that have left their jobs to become nurses in other countries. The number of nursing schools in the Philippines has almost tripled during the past two decades. This shift in health workforce has been detrimental for the Filipino health system as 70 percent of the population die without the necessary healthcare. Rural to Urban Areas For developing countries, the internal migration of health care workers from rural to urban areas is a major concern, as access to health care services among rural populations is reduced. More than 75 percent of physicians, 60 percent of nurses and nearly 60 percent of other health service providers are located in urban centers. Yet about half of the global population lives in rural areas.6 In China, about 68 percent of all health professionals are located in urban areas, leaving more than a two-fold inequality between urban and rural areas. 11 In Tanzania, although most medical students in the final year had grown up in rural areas, more than half are unwilling to work in a rural area after completion of their education. 18 Pilot projects being carried out by governmental health agencies; some linked with the Capacity Project, have been successful in finding mechanisms to retain or encourage health care workers for work in rural areas.18 In Zambia, compensation for school costs and financial incentives for those physicians willing to work in rural areas where shown to increase the number of doctors in rural areas by 53 in two years. In Kenya, health worker satisfaction increased by 30 percent in 10 rural areas after the implementation of inexpensive actions to improve worker environment conditions. Public to Private Sector Health care workers may leave the public sector to work for a nongovernmental organization or another private entity.19 Private sector salaries may be considerably higher than public sector wages, making it easier to support a family when employed by the private sector. In addition to low wages, public sector jobs may lack continuing education opportunities, have poor supervision and management systems and lack the basic equipment and supplies (including medications) needed to provide effective care for patients while incorporating worker safety protocols. These conditions contribute to worker dissatisfaction and fear of being infected with HIV or other diseases. Several recent initiatives, including the President s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria, provide increased health care coordination, infrastructure and funding. Contributing Factors to Health Worker Migration 16

5 To prevent the migration of health care workers, more sustainable incentives, improved working environments, and opportunities for advanced training and certification are needed to mitigate the migration from rural areas and from developing countries. To reduce the need to import health care workers from developing countries, high-income countries need to train a greater number of health workers to meet their growing need.16 1 Chen LC, Timothy E, Anand S, Boufford JI, Brown H, Chowdhury M, et al. Human resources for health: overcoming the crisis. Lancet. 2004;364: World Health Organization. World health report 2000: health systems: improving performance. Geneva: WHO; Harvard University. Human Resources for Health: overcoming the crisis: Harvard University Press; Friedman Eric A. An Action plan to prevent brain drain: building equitable health systems in Africa. Boston: Physicians for Human Rights; World Health Organization. Health workforce definitions. [cited April 19, 2009]; Available from: 6 World Health Organization. World health report 2006: working together for health. Geneva: WHO; United Nations. UN Millennium Development Goals. [cited April 26, 2009]; Available from: 8 Medecins San Frontieres. Help wanted: confronting the health care worker crisis to expand access to HIV/AIDS treatment, the MSF experience in South Africa; World Health Organization. WHO's strategy for strengthening health systems. [cited September 12, 2007]; Available from: 10 World Health Organization. Task shifting : rational redistribution of tasks among health workforce teams. Global recommendations and guidelines. Geneva: World Health Organization; Anand S, Fan VY, Zhang J, Zhang L, Ke Y, Chen LC. China's human resources for health: quantity, quality and distribution. Lancet. 2008;372: Partners in Health. Task Shifting: Sharing another piece of PIH s model with the world [cited May 2, 2009]; Available from: 13 Joint Health Professions. Statement on task shifting [cited February 28, 2008]; Available from: 14 Philips M, Zachariah R, Venis S. Task shifting for antiretroviral treatment delivery in sub- Saharan Africa: not a panacea. Lancet. 2008;371: World Health Organization. WHO global burden of disease (GBD) 2002 estimates (revised); World Health Organization. Fact sheet: migration of health workers. Geneva: World Health Organization; Cheng MH. The Philippines health worker exodus. Lancet. 2009;373: Yumkella F. Worker retention in human resources for health: catalyzing and tracking change. Washington, D.C: USAID; International Finance Corporation. The business of health in Africa: partnering with the private sector to improve people s lives Washington, D.C: World Bank; Comments? Questions? Problems? Contact the Global Health Council. All Rights Reserved. Privacy.

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