Intern doctors chant as they demonstrate with banners and placards outside the Kenyatta National Hospital to demand better terms including permanent employment
Intern doctors in Nairobi demand better employment terms © Tony Karumba/AFP via Getty Images

Put in plain economic terms, the world has a supply and demand problem when it comes to its health workforce.

Demand for healthcare is rising as people live longer and suffer from illnesses such as diabetes and cancer; but the supply of health workers is not keeping up.

A study in the BMJ Global Health journal based on 2020 data calculated that, by 2030, the world would face a shortage of 10mn health workers, compared with what it is thought to need to achieve the UN Sustainable Development Goal of universal healthcare.

The Covid-19 pandemic exacerbated worker shortages, as many staff left the profession, fell ill or died, says Jim Campbell, the World Health Organization’s director for health workforce.

The data on worker shortages also reveals huge inequalities: high-income countries have 6.5 times more health workers per capita than low-income countries in 2020, according to the BMJ study. The biggest shortfall is set to be in the WHO’s African Region.

Campbell says two mechanisms are driving the global health worker shortage.

First, not enough people are training as doctors, nurses and other health workers in higher-income countries, so governments are filling the gap by recruiting from overseas. For example, more than half of the doctors joining the UK’s General Medical Council register since 2018/19 trained outside the UK, according to a Public Health journal paper.

This situation is almost reversed in poorer countries, where more people gain qualifications than there are jobs. “In some of the lower middle income economies, high interest rates mean the debt burden [annual payments to service government borrowing] is greater than the budget for health and education combined, which means there’s no new money to create jobs, even though graduates are coming through the system,” says Campbell.

“There’s a global labour failure through the mismatch in demand . . . and the supply from the education system.”

Lacking job opportunities at home, many health workers go overseas. A WHO report shows that, in the organisation’s African Region, 42 per cent of health workers intend to move abroad in the future, looking mostly to the UK, US, Canada, Ireland and Australia. Yet the region also carries some of the highest levels of disease.

Line chart of Rates of disability-adjusted life years lost to disease, by type of country showing The burden of disease is falling

This migration of health workers surged during the pandemic, according to Dr Matshidiso Moeti, WHO regional director for Africa. Zimbabwe, Nigeria and Ghana were among the countries that saw significant emigration of health workers.

“The economic cost is enormous for African countries,” she says. For each doctor that emigrates, a country loses about $1.85mn in returns from the investment of training them, Moeti says. The region is now “facing a significant impact of unmanaged global health workforce mobility”, she says.

While the WHO advises countries to talk to each other and has issued best-practice guidelines to ensure migration is mutually beneficial, self-interest often wins out.

Medical staff look on as a monitor displays a cornea transplant surgery inside the operating theatre at Lions SightFirst Eye Hospital in Nairobi
A person receives a cornea transplant at an eye hospital in Nairobi © Patrick Meinhardt/AFP via Getty Images

“A minister of health is responsible for the health of their population and, if they haven’t got enough workers . . . they will look to strengthen that,” says Campbell. “We perfectly understand that, but there’s this ethical and moral responsibility. Don’t take from those who have less resource than yourself.”

One solution for alleviating these workforce pressures is “task shifting” — giving some tasks to less highly qualified practitioners, which has been successful in cases including HIV testing in rural communities.

Ultimately, though, “the shortage is too great, the undersupply is too big,” warns Campbell. “When you’ve got health workers who are burnt out, you can’t optimise their performance.”

Rob Yates, director of Chatham House’s Global Health Programme, says increasing public health spending is the answer: “We’re going to need to find more public financing if we are going to meet the needs of an ageing population. We’ve just got to come to terms with this. There’s no alternative.”

That can be a hard sell for a stretched government purse, but Chatham House research has found that moments of true crisis can spark expansion. In parts of Asia, the Sars epidemic led to big injections of spending; Thailand successfully grew its health system when rebuilding from its 1997 financial crash; a similar phenomenon was seen in Rwanda after the genocide; and Britain’s National Health Service was a product of the austere years following the second world war.

In some places more recently, Covid-19 has been that crisis. Kenya, South Africa, Cyprus and Egypt are among countries that have since said they will expand healthcare coverage.

Moeti notes that there has already been a 70 per cent rise in health workers being trained in Africa since 2018. However, creating jobs for these graduates remains the key hurdle. According to WHO predictions, spending on health workforce employment by governments, the private sector and donors needs to increase by 43 per cent to absorb all of the trained health workers in the WHO African Region.

The private sector can play a role, particularly while sovereign budgets remain so squeezed. At least 40 per cent of extra training in the WHO African Region from 2018 to 2022 came from the private sector.

Similarly, development spending can help; in Benin, a temporary tranche of development spending has offered a boost to healthcare provision. However, “multilateral development spending is woefully inadequate,” says Yates. Like everything else, it is not a silver bullet.

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