Human resources for health

The WHO defines health workers as all people engaged in actions whose primary intent is to enhance health. This includes mothers and carers, community health workers and traditional birth attendants. Formal health workers can be classified into two major groups: the health service providers (two-thirds of the formal health workers) and health management and support workers (one-third of formal health workers). WHO estimates the number of full paid health workers worldwide at 59.2 million-a conservative estimate. There is a significant gender imbalance in the health workers' distribution: 70 % of doctors are male and over 70 % of nurses are female. The global shortage of formal heath workers is estimated to be 4.3 million workers.

Globalisation has increased the movement of people across national borders in search of better labour markets and improved quality of life. The push and pull forces underlying international migration also apply to the health sector. The root causes for migration of health workers are related to inadequate remuneration and promotion, limited opportunities for continued education and training, poor working environment, heavy work load, lack of an environment conducive for the development and education of their children. Among the pull factors are prospects for better remuneration, better opportunities for continued education and improved living conditions. The unmet demand for well-trained health workers in developed countries is an important pull factor.

It is acknowledged that there is a global, chronic shortage of trained health workers, most critical in developing countries. Demographic and epidemiological transition and high disease burden, compounded with migration and poor human resource management are some of the major causes of the current human resources crisis. There is no global consensus on the best strategies to address the problem. Data on real numbers, profile, distribution and migration is scanty and difficult to compare in a systematic manner. Migration of health workers from rural areas to urban centres, as well as their regional and international migration, is on the increase, with a major impact on the health system and the quality of services provided.

Although detailed and accurate data is not available for most countries and difficult to compare, it is estimated that emigration of skilled health personnel from developing to developed countries has significantly increased over the past years, with some European countries recruiting foreign trained personnel on a large scale. It is estimated that more than 25% of physicians and nurses in the UK, US, Australia and Canada are foreign trained. It is estimated that 15,000 foreign nurses were recruited into the UK in 2001 and 35,000 more are needed by 2008. With increasing needs for highly skilled health personnel in developed countries-due in large part to the ageing population and epidemiological transition-it is anticipated that this trend will continue over the coming years.

There have been concerns raised over ethics of recruitment of health workers by developed countries and in some cases official policy has stopped direct recruitment for national health systems. But migration continues through professional agencies specialised in outsourcing skilled workers from developing countries. In Europe, it is estimated that there are 1,890 health workers per 100,000 citizens.

In Sub-Saharan Africa (SSA), the average ratio of physicians and nurses per 100,000 people is 15.5 and 73.4 respectively. In selected developed countries, this ratio is 311 and 737.5. The emigration of trained health personnel and other causes (such as HIV/AIDS and macroeconomic policies) can only worsen this already serious situation. The depletion in human capital further reduces the potential for economic growth. Mode 4 of service supply under the General Agreement on Trade in Services (GATS) presents the opportunity for economic gains from the remittances of migrated health workers. However, such remittances at present do not assist the health economies of developing countries which are put at great risk by the continuous outflow of skilled workers, trained over several years at significant cost.

Although there is no consensus on the way forward to manage the human resources crisis, several proposals have been made and the EU should seize this opportunity to take the lead in addressing this increasingly important issue.

There are incipient efforts being made in this regard. As a corollary to the May 2005 communication on "A European Programme for Action to Confront HIV/AIDS, Malaria and Tuberculosis through External Action" (COM (2005) 179), which identified the lack of health workers as a major barrier to fight the three diseases, the European Commission issued the "EU Strategy for Action on the Crisis in Human Resources for Health in Developing Countries" (COM (2005) 642 final). This communication outlines concrete actions to be taken by the Union at the national, regional, and global level, in support of human resources capacity building, including mobilising funding for training programmes and the development of a health workforce in developing countries, promoting the ethical recruitment of foreign workers, working with the health worker diaspora and promoting return programmes, strengthening the social dimension of globalisation, and promoting decent work as a global goal for all. This plan of action was discussed and ratified by the EU Council during the General Affairs and External Relations Council (GERC) meeting in Luxembourg in April 2006. As of 2008, the European Commission has been working on an EU Code of Conduct of ethical recruitment of health workers. To be effective such a Code of Conduct requires that all employers across a sector sign up-including the private sector-and that the ethical recruitment practices extend to all industrial countries and not just the EU. The EU should take care not to only devise its own insular rules and regulation, but to link progress at the European level to similar initiatives at the global level. Furthermore, as proposed by WHO, there is a need to develop and implement strategies in source countries (adapt training to needs and demands, improve working and living conditions), in receiving countries (fair treatment of migrant workers, responsible recruitment policies, etc.) and internationally (implementation of ethical recruitment policies and codes of practice, etc.), in order to mitigate the impact of international migration on the health workforce crisis.

There is also a need to develop strategies to address the shortfall in human resources to contribute to the achievement of the internationally agreed goals, such as the Millennium Development Goals, deal with the increasing burden of non-communicable diseases both in developed and developing countries and confront the threat of emergencies and epidemics such as avian flu. Adequate management of supply and demand requires careful planning of needs in the various categories of health workers, taking into account the possibility of innovations in working practice. Training institutions, private sector and civil society should be involved in this process.

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