Stem the sharp decline in health worker numbers by prioritizing retention, recruitment and competency based education in humanitarian settings

Skilled and competent health workers are an essential element of  robust well functioning health systems for women, children and adolescents. However the availability of many health workers, in all sectors, is worryingly low and worsens further during states of emergency.

Before the pandemic, the world was short of almost six million nurses, mostly in low- and lower middle-income countries. COVID-19 has pushed the shortfall towards seven million and beyond. There is also a global shortage of 900 000 midwives, which represents a third of the required global midwifery workforce. In the United States alone, there is a projected shortfall of up to 22 000 by 2050.

Gaps like these are seen across the health workforce. Although a global issue, sadly it is often worst in resource poor, remote and rural settings where establishing the workforce is hardest. These countries have the lowest number of health care workers, many of whom receive insufficient training. With fragile health systems and without a strong health workforce, these settings often have the poorest health outcomes for women, children and adolescents.

Without additional recruitment and retention, by 2030, WHO project a global shortage of 18 million health workers, mostly in low- and lower-middle income countries. Data from 121 countries on the density of the paediatric workforce from International Paediatric Association in 2019 highlighted a huge discrepancy, with 0.5 paediatricians per 100,000 children in low-income countries and a median of 72 paediatricians per 100,000 children in high-income countries. 

More than ever before, health workers everywhere are stretched desperately thin and the current health workforce is insufficient to meet the need of the worlds women, children and adolescents. 

Causes of the problem

There are historical and structural reasons for health worker shortages, stemming from decades of underinvestment and failure to prioritize the roles and needs of health workers within health systems.

Current recruitment levels and growth in capacity of health workers is insufficient due to an ongoing mismatch between education and supply strategies, health systems and population health needs. Additionally a major cause of the shortage in LMIC countries particularly those in conflict is the migration of health care workers from their countries to more developed countries, a phenomenon known as the "brain drain". The problem is not only due to poor working conditions in poorer countries but also due to active recruitment by richer countries. On top of this, the workforce is aging which would not be of concern if there was a growing cohort of younger health workers occurring alongside it. However, health services are not recruiting fast enough to replace those who leave. In the US, less than 1 in 5 (19%) of the nation’s obstetricians and gynaecologists are younger than 40 years old. Thus the gap in numbers and expertise gets ever wider. For example- without sufficient recruitment and retention, the world could face a shortage of up to 13 million nurses, nearly half the nursing workforce by 2030.

In particular the pandemic has placed immense pressure on health systems, including on the health workforce.  With resources shifted to combat COVID-19, many health workers were denied the basic resources needed to provide essential services for the women, children and adolescents they care for. In 2021, the third WHO pulse survey estimated that one third of reproductive services globally remain disrupted. Additionally, shortages in personal, protection equipement and vaccines have left workers vulnerable to succumbing to COVID-19 infection. Despite this, many continued to work on, resulting in an unimaginable pressure and workload.

Recent global shocks including new and ensuing conflict has left health workers in challenging and unsafe environments. PMNCH’s board chair Helen Clark recently co-authored a piece in the BMJ opinion, highlighting the challenges healthworkers are facing in delivering essential services. Instead of getting more support, many healthworkers are getting less. For example, in Afganisatan, the Nursing and Midwifery Council regulatory body was disbanded, leaving nurses and midwives working around the clock in unsafe settings, often without support or pay.

Health workers are not made of stone. Like all human beings they too have suffered fatigue, stress and burn-out. To protect their mental and physical health and well-being, many feel compelled to take time out, or even leave their professions completely. This is happening across the world. An experienced nurse in Switzerland described: “I went to my boss's office and cried, I said ‘But I have the impression that I am caring…like a fool … I [don't] feel safe ….’”

An obstetrician in Agra, India described: “We have been in chronic fatigue and the Covid-19 pandemic has broken us but we had no choice but to go all out to help those that are suffering. The staff are getting scared and not feeling safe in their present working environment. How can this go on?”

How can we stem the sharp decline in health-worker numbers and give them the support and resources they need?

Solutions

First, the world should recognize that well-trained health workers are an essential investment for a resilient health system. The Lancet noted that fully resourcing midwife-delivered care by 2035 could avert 67 per cent of maternal deaths, 64 per cent of newborn deaths and 65 per cent of stillbirths. It could save an estimated 4.3 million lives per year.  Explicit focus on training and recruitment of the health workforce is needed in vulnerable regions where health-worker numbers are lowest. The recent WHO Health and care worker compact highlights the importance of protecting, safeguarding and investing in the health care workforce. When health workers are trained effectively, they deliver. A clear example of a positive health workforce solution for caring for refugee populations has been the WHO Refugee Health Programme, where almost 2000 Syrian health workers have been trained in 7 refugee health training centres to work in a network of up to 178 refugee health centres throughout Turkey. Countries must look to novel context-specific strategies such as these to ensure adequate training and support of the health workforce.

Health workers must also be supported to lead effectively. Country leaders should champion all health care workers and ensure full representation and inclusion across disciplines during high-level meetings and decisions. There is also a need to close the gender gaps in healthcare workforce.  where women are almost 70% of the global health and social workforce but it is estimated they hold only 25% of senior roles. During the COVID19 pandemic women have provided much of the health and care, but have not had an equal say in decision making. This pervasive leadership gap between women and men in health can only be closed by addressing systemic barriers to women’s advancement.

Better, up to date, complete contexualised data is necessary to inform policies decisions and action. In 2016 the UN High-level commission on investing in health workforce and economic growth highlighted better data, information and accountability as one of the ten key pillars to transform the health workforce for the SDGs. Governments must invest in mechanisms to collect data in real-time,  especially during health emergencies, for better response plans.

Retention of existing health care workers is necessary and can be achieved through newer innovative models of care (eg. The WHO Global Strategic Directions for Nursing and Midwifery.) Developing countries have a responsibility to safe-guard their healthworkers and provide an enabling workplace environment to mitigate against the brain drain phenomena through a focus on Ethical Migration. There are numerous examples of ethical migration having been implemented successfully with trade agreements. Careful consideration must be taken to reward, recognise, and renumerate health workers adequately, to ensure they are supported and can work safely – for example, through early access to full vaccination programmes.

Governments need to focus on priorities and plan ahead. The pandemic in particular has left such destruction in its wake and we must prioritise healthworkers in preparedness plans from the offset. It is imperative that an assessment of pandemic-related damage to health systems is undertaken to identify priority areas for health worker recruitment and competency based education. Explicit prioritisation of health-workers, including for the health workers needed to serve the needs of women, children and adolescents, must be made in the new international instrument on pandemic preparedness and response.

PMNCH is driving this agenda through its HCPA constituency. Only by listening to the views of those on the front line can we make real change and action happen. Within our 2022-2023 advocacy goals, we highlight the need to strengthen the health workforce, including midwives, nurses, doctors and all health clinicians caring for women, children, and adolescents, as a key focus for initiatives.

This opinion piece is written by the following members of the PMNCH Health-Care Professionals Associations Constituency:

• International Confederation of Midwives (ICM)- Franka Cadée, Harriet Nagiya, Mandy Forrester
• International Council of Nurses (ICN)- Anne Sylvie Ramelet, Michelle Acorn
• Council of International Neonatal Nurses (COINN)- Carole Kenner, Karen Walker, Debbie O’Donoghue
• International Federation of Gynecology and Obstetrics (FIGO)- Bo Jacobsson, Jaideep Malhotra, Jeanne Conry, Mary- Ann Lumsden, Yvonne Diaz
• International Pediatric Association (IPA)- Christiana Russ, Errol Alden, Jon Klein
• Junior Doctors Network, World Medical Association (JDN, WMA) - Eglė Janušonytė