JAMA Global Shortage of Health Workers, Brain Drain Stress Developing Countries

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1 Vol. 298 No. 16, October 24/31, 2007 Medical News & Perspectives JAMA Global Shortage of Health Workers, Brain Drain Stress Developing Countries Bridget M. Kuehn JAMA. 2007;298: A worldwide shortage of health care workers, coupled with a disproportionate concentration of health workers in developed nations and urban areas, stands in the way of achieving such key public health priorities as reducing child and maternal mortality, increasing vaccine coverage, and battling epidemics such as HIV/AIDS. Currently, there are 2.4 million too few physicians, nurses, and midwives to provide essential health interventions, according to the World Health Organization (WHO), a shortage that will require adopting a global approach to health worker human resources. Various groups, including the WHO, professional organizations, and others are working to address both the global shortage as well as the circumstances and practices that encourage the disproportionate migration of health workers from developing nations to wealthier countries. A variety of phenomena have contributed to the existing global shortage of clinicians. The WHO's 2006 World Health Report outlined many of the causes of disproportionate health worker migration. For example, in developed countries, predominantly in the northern hemisphere, a growing aging population and increasingly high-tech health care are

2 underinvestment in health worker education has left developed nations with too few domestic health workers to meet the demand, according to the WHO report. In many less developed countries, predominantly in the southern hemisphere, economic policies limit investment in public-sector health care and reduce funds for health worker education. At the same time, according to the WHO, the AIDS epidemic has placed unprecedented burdens, including high rates of HIV-related illness and death among health workers, on these already stressed health systems. Faced with poor working conditions and limited economic prospects in their home countries, many health workers choose to migrate to fill the demand in wealthier nations.

3 SUBSIDIZING WEALTHIER NATIONS For poor countries, the costs of the outflow of health workers can be considerable. When developing nations pay to educate their health care workers only to have them leave for developed nations, they are, in effect, subsidizing wealthier nations, notes the International Organization for Migration. The organization estimates that developing nations spend $500 million each year to educate health workers who leave to work in North America, Western Europe, and South Asia.

4 Additionally, health systems that are already weakened by epidemics or a shortage of health workers may further falter or collapse. For the past 3 years, the African Ministers of Health have brought resolutions to the annual meeting of the World Health Assembly (the policymaking body for the WHO), stating that migration of health workers from their countries is crippling their health systems. For some of these nations, the migration of 1 or 2 specialists in a given field may strip the country of half or all of its skill base in that field, explained Francis G. Omaswa, MD, executive director of the Global Health Workforce Alliance. These unchecked flows of health workers leave regions with the greatest health care needs with the fewest workers. For example, 37% of the world's health care workers live in the Americas, predominantly in the United States and Canada, yet these countries carry only 10% of the global disease burden. In contrast, Africa is home to only 3% of the world's health care workers, yet it has 24% of the global burden of disease, according the 2006 WHO report. Beyond problems associated with global migration, many nations face severe shortages in rural areas as health workers flock to urban areas, sometimes as a stepping stone to work abroad, the report notes. PUSH AND PULL Correcting these imbalances will require a delicate balancing act that protects the right of individual workers to legally migrate while ensuring that global health care needs are met. In an effort to craft and promote such an approach, the WHO has launched the Health Worker Migration Policy Initiative. The initiative brings together professional organizations and other groups to develop a roadmap and code of practice for health worker migration. Simultaneously, individual organizations have launched their own efforts to encourage ethical recruitment of health workers, and to spread the benefits of health worker migration more equitably among developed and developing nations. Omaswa, who is co-chair of the WHO Health Worker Migration Policy Initiative, said the initiative will build on existing national and international guidelines for health worker migration to develop a voluntary code of practice that nations can use to develop regional or bilateral agreements. Bilateral or multilateral agreements are seen by many as key to ensuring that developing nations also benefit when their workers migrate to developed nations. For example, the United Kingdom and South Africa have an agreement that allows time-limited health care worker exchanges and the pairing of UK and South African hospitals to facilitate sharing best practices. Such agreements can also help prevent "brain waste," which occurs when skilled migrant workers are unable to find work in their area of expertise and end up working in unrelated low-paying jobs. International agreements can facilitate this by improving the training of workers in their home countries and helping employers in recruiting countries to understand cultural differences, training strengths, and areas in which workers may

5 need additional training, explained Mary A. Pittman, DrPH, president and CEO of the Health Research and Educational Trust (an affiliate of the American Hospital Association) and a participant in the WHO initiative. While preventing brain waste won't reduce the migration of workers, it will help ensure that migrating workers skills aren't wasted, and allow the workers and their home countries to potentially benefit from bilateral agreements. "It's important to know how to best integrate these individuals into the workplace," Pittman said. The code developed by the WHO initiative will call on governments in both developed and developing nations to address so-called pull factors that attract workers to wealthy nations and push factors that make staying in their home countries unappealing. To accomplish this, developed countries must produce enough health workers to meet their countries' needs, Omaswa said. He acknowledged that these efforts will take a considerable amount of time and be very difficult. In countries such as the United States, such efforts will be multifactorial and may take generations to accomplish. Currently, professionals outside the United States make up one-fourth of the US physician workforce and 4% of the overall nurse workforce, according to the American Public Health Association. Few data are available on the number of international workers in other health care professions in the United States. By 2020, the US Health Resources and Services Administration projects the nation will face a shortage of more than 1 million nurses and about physicians. PRIMING THE PIPELINE To correct these shortages a multitude of issues must be addressed, including adjusting the way health professional training programs are funded. Additionally, more young people will have to be attracted to pursue health care professions, a process that begins before the sixth grade, said Georges C. Benjamin, MD, executive director of the American Public Health Association, which adopted a policy on ethical recruitment of internationally trained health professionals in "We need to get the pipeline primed," said Benjamin. As developed countries work toward self-sufficiency, Omaswa said, they must support developing countries that supply workers by providing funds for training health care workers and for building infrastructure. One such program aims to bring some of the expertise of internationally trained health care workers back to their home countries. The International Organization for Migration has developed a pilot program called Migration for Development in Africa, which is working to mobilize the diaspora of African health care workers to help build and strengthen health care systems in Africa. As part of the program, the organization

6 secured funding and support from the Netherlands to survey Ghanaian health care workers in the Netherlands and Europe to identify skill sets in this group. The group also conducted a needs assessment of the health care system in Ghana. Now, the group is working with 10 Ghanaian health care professionals employed in Europe to match their expertise with needs in Ghana and arrange for the workers to temporarily return to Ghana to share their expertise through teaching or other assignments. Anita Davies, MD, of the International Organization for Migration, said such temporary work may open doors for the workers to permanently return to their country. Additionally, the program is exploring virtual exchange opportunities, in which Ghanaian workers may develop teaching modules or teach students in Ghana via such tools as videoconferencing. Developing nations, on the other hand, must strive to improve working conditions for health care workers by boosting pay, creating opportunities for workers to advance, making more training available, and increasing overall health funding to make essential drugs and equipment widely available, Omaswa said. One country that has launched such an effort is Malawi, according to the WHO report. In the face of inadequate health care staffing to provide basic health care or deliver HIV/AIDS related services, the country in 2004 launched a $278 million 6-year Emergency Human Resources Programme, with funding support from the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United Kingdom Department for International Development, and other donors. The program includes financial and other incentives to boost recruitment and retention, salary increases, improved housing for staff, better management of health workers, and expansion of domestic training programs. By 2005, 5400 physicians, nurses, and other health care staff had received salary increases and more than 700 new health staff had been recruited. Plans to expand domestic training programs called for tripling the number of physicians-in-training and nearly double the number of nurses-in-training. While health worker migration from poor to wealthier nations will undoubtedly continue, improving conditions for health care workers globally will make it easier for larger numbers of workers to stay in their home countries, said Omaswa. "We believe that a great majority of people want to stay near their families and loved ones," he said. "There may be a few adventurous individuals who wish to migrate, but most people will want to stay put if they can."

7 Resources on Health Worker Migration World Health Organization World Health Report (http://www.who.int/whr/2006/en/) and fact sheet on migration of health workers (http://www.who.int/mediacentre/factsheets/fs301/en/index.html). International Organization for Migration. Background on and strategic plan for the organization's Migration for Development in Africa program (http://www.iom.int/mida/). American Public Health Association. Policy on ethical recruitment of international health workers (http://www.apha.org/programs/globalhealth/section/advocacy/globalihtest2.h tm).

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