Eric Williams — Push and Pull Factors Affecting Attrition of Health Workers

The global shortage of health workers poses one of the greatest challenges to health and development for developing nations. The World Health Organization estimates that 57 countries – 39 of which are African nations – have severe shortages and require some 4.3 million health workers to fill immediate and critical gaps in fragile health systems.

For better perspective, consider the following excerpt from a statement by an international coalition of organizations and individuals concerned with how certain proposals to address the U.S. domestic health worker shortage have  “significant potential to worsen international health outcomes,” particularly with respect to the global supply of health workers:

“While the United States enjoys workforce ratios of 8 nurses and 3 doctors for every 1,000 Americans, in Ghana more than 10,000 people have to share a single doctor, and India has less than one nurse for every 1,000 people. Washington, DC, with a population of fewer than 600,000 people, has about twice as many physicians as do the more than 80 million residents of Ethiopia.”

Health worker safety, salaries, benefits and a host of other issues are “push” factors driving health workers to leave the health sector or forcing them to migrate to other regions and countries for better pay and safer work conditions. Additionally, “pull” factors fuel a brain drain to richer nations where higher salaries, stable governments, and better schools are available for health workers and their families.

There have been large increases in development aid over the last decade – though still inadequate – for developing nations, rich nations are part of the problem. Rich nations recruit health workers from lesser developed countries to meet their own growing health demands. It is estimated that 25%, or 200,000, of U.S. physicians were trained overseas and that 60% of those physicians were trained in low to lower-middle income countries. And among nurses, the U.S. nurse workforce now includes 400,000 foreign trained nurses – 16% of the entire nursing workforce. Such drains on developing nation health workforce only further exacerbate widespread shortages and makes it all the more difficult to address endemic and epidemic challenges such as HIV/AIDS, TB, malaria, reproductive and maternal child health issues, neglected tropical diseases and so on.

There is much that donor and developing country governments must do to address the health worker crisis and to strengthen health systems, including:

• Supporting robust health workforce plans and providing needed funding
• Funding commitments
• Code on international recruitment of health personnel
• Increasing number of domestically-educated health professionals
• Other relevant activities or developments

The full list of recommendations developed by the Health Workforce Advocacy Initiative can be found here.

The U.S. government officials announced in May 2009 a new comprehensive strategy under development that is to be an “integrated approach to fighting diseases, improving health, and strengthening health systems.” In a report released in late October 2009, a broad coalition of advocates and implementers called for a doubling U.S. aid for health and establishing U.S. targets for improved health outcomes. Health workforce plays a prominent and central role in the report.

Eric Williams is a Policy Associate at Physicians for Human Rights (PHR), a nonprofit that “mobilizes health professionals to advance health, dignity and justice, and promotes the right to health for all. Harnessing the specialized skills, rigor, and passion of doctors, nurses, public health specialists and scientists, PHR investigates human rights abuses and works to stop them.” Eric is based in PHR’s policy office located in Washington, D.C., but the nonprofit’s primary office is in Cambridge, MA.

PHR chairs the Health Workforce Advocacy Initiative (HWAI), which is an international civil society-led coalition affiliated with the Global Health Workforce Alliance. HWAI prioritizes human resources for health and health systems strengthening, and seeks to ensure that people everywhere have access to skilled, motivated and supported health workers within well-functioning health systems.