Where the Healthcare Workers Are

At the Millennium Development Goal summit last month, one of the sessions addressed the issue of the global healthcare workforce. We don't have enough healthcare workers to deliver needed care to the world's population, and until we address this problem it'll be next to impossible to meet the goals of reducing child mortality, improving maternal health, and combating diseases like AIDS and malaria.

One major challenge is simply that there aren't enough trained healthcare professionals, but the distribution of the existing healthcare workforce is also a pressing issue. At the global level, developed countries lure doctors and nurses from the developing countries where they were trained; one-fourth of physicians practicing in the US are international medical graduates.

In 2006, the World Health Organization put out a report on the issue of the global healthcare workforce. It includes the number healthcare workers per 1,000 population, and the regional differences are stark:

Africa: 2.3
Eastern Mediterranean: 4.0
South-East Asia: 4.2
Western Pacific: 5.8
Europe: 18.9
Americas: 24.8

Recommendations for fixing this gross imbalance address the training of workers, their work experiences, and the pressures and incentives that can cause departures from local healthcare workplaces. In terms of preparing the workforce, the report recommends building strong educational institutions, assuring educational quality, and revitalizing recruitment capabilities. To enhance the performance of the existing workforce, recommendations include supportive-yet-firm supervision, fair and reliable compensation, provision of necessary resource (clean water, heating, drugs, equipment, etc.), and ongoing learning opportunities.

Hazards that Can Drive Workers Away
The issue of safe work environments comes up in the context of ensuring retention. Violence against health workers is a big concern, in both developing and developed countries, and the report notes that it's of particular concern for women. The Joint Programme on Workplace Violence in the Health Sector has issued Framework Guidelines for Addressing Workplace Violence in the Health Sector, and they include recommendations for governments, employers, workers, professional bodies, and communities.

Healthcare workers also face risks of infections from improperly disposed-of medical waste such as used needles. The WHO report gives some numbers:

Each year, 3 million health workers worldwide are exposed through the percutaneous route to bloodborne pathogens: 2 million are exposed to hepatitis B, 900 000 to hepatitis C and 170 000 to HIV. These injuries result in 15 000, 70 000 and 1000 infections, respectively. More than 90% of these infections occur in developing countries.

Appropriate protective equipment and proper cleanup and disposal of biomedical waste can prevent a great deal of worker exposure to pathogens, and WHO also recommends routine immunization of hepatitis B.

Musculoskeletal injuries are also alarmingly common in the healthcare workforce, particularly among those responsible for patient handling. Such injuries can be a significant source of lost time, as well as a factor in healthcare workers' decisions to leave their profession.

Managing Migration
As long as stark differences in countries' median incomes persist, there will be financial incentives for healthcare workers to migrate for higher pay. Increasing the pay of healthcare workers in poor countries is one way to improve retention, but budgeting realities might make that difficult. Improvements to workplace safety, flexible scheduling and leave policies, supportive supervision, and ongoing learning opportunities are other ways that healthcare jobs can become more appealing even if wages don't rise.

The countries that are recruiting healthcare workers from abroad also have a responsibility to ensure that these workers are recruited honestly (i.e., without promises of jobs or benefits that can't be guaranteed) and treated fairly. The WHO report recommends:

The scant but increasing evidence on the experience of migrant health workers raises concerns related to their unmet expectations on remittances, personal security, racial and cultural isolation and unequal work conditions, with limited knowledge of their rights and the ability to exercise them. Migrant workers should be recruited on terms and conditions equal to those of locally recruited staff and given opportunities for cultural orientation. It is vital to have policies in place that identify and deal with racism among staff and clients.

The report also suggests that countries recruiting healthcare workers from poorer countries provide aid to address those countries' healthcare needs, such as sending personnel to assist with training or deliver healthcare services after a disaster or during a disease outbreak. Such assistance sounds paltry in comparison to the massive brain drain that we in the developed world are causing, though.

Internal Migration - and Mobility
As Laurie Garrett warned in a 2007 Foreign Affairs article, the effect of developed countries' actions on developing countries' healthcare workforces aren't limited to luring workers from one country to another. Garrett explains that high-profile initiatives to fight AIDS, tuberculosis, and malaria, are funded by international organizations and can offer higher salaries that lure healthcare workers away from hospitals and clinics - so, healthcare workers may remain in developing countries, but no longer provide the basic healthcare services that the local population so desperately needs.

Even without the intervention of well-funded disease-specific initiatives, healthcare workers worldwide tend to gravitate towards jobs in certain desirable areas (in terms of both practice and geography) and leave others without sufficient personnel. Within a given country, the more urbanized and high-income areas are likely to have more doctors per capita. Here in the US, we also have a shortage of primary doctors as more and more medical school graduates choose to become specialists. None of this is surprising, but we haven't put enough effort into altering recruitment, training, and incentives to address the disparities.

This is a grim global picture, but when got me started on writing this post was actually an optimistic a New York Times Opinionator piece by Tina Rosenberg and David Bornstein about the role of motorcycle maintenance in developing-country healthcare. They write about Tsepo Kotelo, who provides health services to people in remote mountain villages in Lesotho and has expanded his reach thanks to an organization called Riders for Health:

Until 2008 Kotelo could visit only three villages a week, because he had to reach them on foot, walking for miles and miles. But in February of that year, Kotelo got a motorcycle â the best vehicle for reaching rural villages in Africa, most of which are nowhere near a real road. Just as crucial, he was given the tools to keep the bike on the road: he received a helmet and protective clothing, he was taught to ride and trained to start each day with a quick check of the bike. His motorcycle is also tuned up monthly by a technician who comes to him. Now, instead of spending his days walking to his job, he can do his job. Instead of visiting three villages each week, he visits 20. Where else can you find a low-tech investment in health care that increases patient coverage by nearly 600 percent?

The challenge of having enough skilled healthcare workers in the places where people need them is a daunting one. Much of the solution is simply to devote more resources to training workers and making sure their jobs are healthy and safe, but there's also a role for creative thinking about how we deliver healthcare services in the first place.