Four Million Short: The healthcare worker shortage

An interview with Lincoln Chen

Lincoln Chen is a distinguished professional in international public health and development. In 2001 Dr. Chen founded the Global Equity Initiative at Harvard University. He is the former Special Envoy of the World Health Organization Director-General in Human Resources for Health.  In 2002, with several other world health leaders, Dr. Chen formed a Joint Learning Initiative to respond to the crisis of dwindling human resources for health in many parts of the world. JLI on Human Resources for Health (JLI-HRH) took an open, collaborative and decentralized approach to engaging this emergent global problem. The project culminated with the publication of the original JLI report, Human Resources for Health: Overcoming the Crisis.

Multinational Monitor: What is the scale of the healthcare worker crisis in developing countries?

Lincoln Chen: In 2000, the UN, the G8 and others announced very major global health ambitions, known as the Millennium Development Goals, which included treatment for HIV infection. What has since became obvious is that the human infrastructure — the backbone of the healthcare delivery system — is too feeble to achieve those global goals.

The Joint Learning Initiative calculated that to come anywhere close to the Millennium Development Goals, a density of 2.5 doctors, nurses, midwives and other health workers per thousand population would be necessary.

Africa has less than half of that level, meaning that African countries would need an additional one million workers. The World Health Organization (WHO) in the 2006 World Health Report did a global estimate and concluded that developing countries would need more than 4 million additional health workers.

MM: How does the density problem vary in developing countries, across regions?

ChenAfrica has a density of less than one doctor, nurse, midwife per thousand population. Europe and North America have 10 or more workers per thousand population. So there’s a 10-fold difference, just in terms of the numbers, let alone differences in the number of years of schooling and the intensity of supervision and support of the workforce.

MM: Is this an Africa-specific or an Africa-only problem?

ChenNot at all. There are massive shortages in Asia, particularly in South Asia, and in most world regions. You may have countries where the averages are adequate but there are disadvantaged communities in that country unable to attract and retain skilled professionals.

There may also be surplus in the midst of scarcity. Some good examples are exporting countries like India and the Philippines, which have rural areas that lack health professionals, yet which export highly skilled doctors and nurses to more advanced industrialized countries.

MM: Generally speaking, what is the rural-urban contrast for healthcare workers in developing countries?

ChenIt’s very hard to retain highly skilled and advanced workers in backward areas for compensation and family reasons, understandably so.

That’s why there’s a lot of interest in the use and development of community health workers and other paraprofessionals. They can perform the key essential tasks that a healthcare system needs to provide at the primary level, while enabling countries to also develop the more specialized and advanced capabilities that are more typically found in tertiary hospitals. The appropriate spread between that basic worker to the most advanced specialist depends on a country’s economic conditions, epidemiologic profile, and available types of technologic and other resources to treat the major problems.

MM: What are the health consequences of these shortages?

ChenThe shortages mean that we have growing health inequities — gaps between what is possible, sometimes even affordable, but can’t be delivered and can’t be implemented because of shortfalls in the human element of a labor intensive service industry.

MM: How does the healthcare worker shortage impact HIV/AIDS?

ChenHIV/AIDS is a huge global problem for which we have treatment, but for which we’re not able to achieve universal access because of economic and healthcare delivery barriers. It is illustrative of a whole set of problems where we have the capability to do much better than we are doing right now.

There are other problems where the disease may be more unique in the poorest communities and we don’t yet have the drugs or vaccines to address them. The moral dilemma may not be as severe, although many argue we should be investing more in research and development to develop the vaccines and drugs for these important problems as well.

MM: You talk about the triple threat from HIV — how it is highlighting but also exacerbating the problem of healthcare worker shortages.

ChenHIV has exacerbated the chronic underinvestment in the health workforce in three ways. Obviously it presents huge workload challenges in the facilities swamped with HIV patients. Then the health workers themselves are on the firing line of transmission of the disease by various kinds of accidents and injuries. And there is the direct effect on the health worker, both the attrition due to HIV or the fatigue and the morale problems of just being palliative agents rather than being healers of people.

MM: Brain drain has been a problem for developing countries for many decades. Is there something new about what’s happening now in the health field?

ChenThe export or migration of highly skilled health professionals from poor countries to rich countries obviously can exacerbate the situation in the poor countries.

In the United States, one quarter of our physicians is imported. We have a huge nursing shortage, so we are now actively importing nurses from other countries. Many come from countries that don’t have a shortage problem and have simply trained people for export. But many others come from the poorest countries, where the flight of the highly skilled can have corrosive effects on the healthcare system in the country.

These people have received a lot of the public investments in education in the home country, so their departure represents a lost investment in time and money. This can be very demoralizing to the countries.

MM: To what extent are the importing countries culpable? To what extent are they actively recruiting and drawing out these trained workers from other countries?

ChenThere is an active recruitment process. Much of it goes on in the private labor market. Some governments also undertake proactive recruitment.

But it’s a two-way street. Most of the people who migrate wouldn’t want to do so if they could do productive work, make a decent livelihood and grow their families in their home environment. So there’s definitely a push factor from the inability of the health system and the employment market in these countries to retain these workers, in addition to the recruitment and pull.

We have to recognize that for many countries in the rich North, the importation of workers is a chronic, longer-term strategy. It is, for example, built into the nature of the American medical human resource development strategy.

MM: To what extent is that true for other rich countries?

ChenIt’s true for all the Anglophone countries: the United Kingdom, Canada, Australia, New Zealand. They’re all importing about a quarter of their health workers. There may not be as much importation for other rich countries, particularly with language barriers. But you’ll see movements from Eastern to Western Europe now, with the expanding European Union market. You’ll see in the Middle East, the importation of Indian and Pakistani physicians into the oil-rich economies. This is by no means a single flow; it’s multiple flows.

MM: You’ve mentioned the failure of policies in countries to retain workers. Can you expand on the nature of the underinvestment in healthcare workforces in developing countries, and especially in Africa?

ChenThere are two types of investment needed to retain workers. The first is to provide a productive work environment where a professional can realize his or her career aspirations, and the second is to have sufficient remuneration and benefits to enable workers to take care of his or her family. Those are the basic parameters of a productive work environment in any country.

When the salary differentials between countries become very large in medicine, as in other fields, the worker will begin to sense that his or her career or family situation will be better served by migration. Sometimes this migration takes place even though the migrating worker may encounter inhospitable conditions upon entry into a rich country — because of unethical recruitment or other practices where workers who are recruited are sometimes not treated with all the dignity and benefits that they’ve been promised at the beginning of the recruitment.

In addition to focusing on the work environment and compensation, more investment is needed in educational infrastructure. Societies need to invest in their educational systems to be able to produce human resources for health.

MM: Has there been a change in the level in investment, support and salaries in developing countries for healthcare workers in the last few decades?

ChenSince the 1980s, we’ve had structural adjustment and a tightening of the belt in much of Africa’s public sector budgets, and so there was both a capping of the number of workers and also quite often a freezing of public sector salaries. Recently, there has been more relaxation and some growth. In a few countries, like Malawi, there have been fairly bold efforts to rehabilitate, grow and strengthen the workforce through significant increases in salaries.

MM: To what extent are International Monetary Fund (IMF) policies, in particular, an ongoing limitation on investment in the health sector?

ChenMany people feel that the IMF imposition of fiscal discipline, with the nature of a health crisis like HIV in some of the poorest countries, and the promise of technologies and what they could do to save lives, are not yet in synchronization. A lot more resources will be needed in these countries if they’re going to be able to save lives.

How the balancing of the fiscal discipline with the health potential is to be matched, I think, is a political and moral quandary that the countries themselves need to address. IMF policies should try to support those rather than simply override choice by forcing a focus on only one component of this difficult balancing act.

We don’t know how much more resources will be needed to use all the drugs and mobilize the workforce effectively to save lives, nor what that would look like in budgetary terms or how it would comply with or violate IMF guidelines. I think one would have to be extremely practical and look at these issues on a country-by-country basis. It may mean that sustainability or fiscal discipline from an IMF position might have to go beyond simply sovereign nation-states. Health is a global, transnational issue. It may very well be that we need to be brother’s keepers, and rely on long-term financial transfers from rich to poorer countries to help with such a humanitarian health issue.

MM: To what extent should the investment in community healthcare workers be expanded? What is the realistic role for community healthcare workers?

ChenMost community health worker experiments on a large scale have not worked well. But many have worked, and we know what it takes to make them work.

The pre-training of workers receives a lot of attention, but perhaps even more important is continuous training, supervision and support of the briefly-trained workers. They must be well compensated and accepted and embedded in the communities in which they live and work.

This is not a phenomenon of only poor countries. In the United States, community health workers are important for healthcare in Alaska, on the American Indian reservations, and in other communities which are not able to attract highly skilled professionals. And so in all societies community healthcare workers can be made to be more effective, but it is very much a continuous supervision and support system with regular feedback, strengthened by good pre-service and ongoing education and training, that will make the difference. It certainly needs adequate financing and continuous improvement. It is not just simply training a lot of workers and then sending them out there.

MM: Should families have a formal role as providers in the healthcare system?

ChenThe families are the primary healthcare providers, so family members should be seen as the front line. But the first-tier of trained professionals, for example the community health worker, brings additional skills for linking families to knowledge, technologies and services.

But the family is the frontline. Data show that when you educate a mother, you’ll get good family health all around. It’s not just supplying the services but it’s also families demanding and accessing available technology and services and then interfacing and being compliant with the knowledge that’s transmitted by a primary healthcare worker.

MM: Do you see a role for compensation for family caregivers?

ChenThere are experimental schemes that give incentives and compensation to families for positive health education behavior like Mexico’s PROGRESA [The Education, Health and Nutrition Program of Mexico] program. For the poorest families, let’s say a poor family wracked by HIV where there are orphans in the household, a family allowance could be an incentive to meet health and education performance standards.

MM: In terms of remedies for brain drain, what is your view of proposals to restrict workers’ ability to move across borders?

ChenI don’t support restricting the human right of people to move across borders. There’s an entry question and an exit question. I could see countries deciding not to allow people to come in. But I’m against countries not allowing people to leave if they want to leave.

MM: Given the global inequities you’ve described, some have proposed a compensatory mechanism by which rich, importing countries pay exporting, poorer ones. Your group rejected that approach.

ChenWe did not support that for three reasons. The first is that all the rich countries have refused to have that be put on the table for discussion; the issue has prevented rather than promoted dialogue and negotiations. Secondly, it’s not clear who would pay whom how much. South Africa, for example, is exporting to Canada, the United Kingdom and the United States, but South Africa also recruits a lot within Africa, from Tanzania, Uganda, Zambia and elsewhere. So who would actually get the money and then how much?

There is also some controversy about precisely how negative the impact is on the home country, because the workers that have migrated send back remittances, which is a positive economic flow back to the home country.

The Joint Learning Initiative argued that we should be looking for positive sum solutions. What if the Northern countries were to massively invest in the educational capacity of the poorest countries? Then the poorest countries would be able to produce many more better qualified health professionals, both for themselves and for any that would then enter the international labor market.

There is a task force being led by the African Union Social Commissioner, Bience Gawanas, and Lord Nigel Crisp of the United Kingdom, on a rapid scaling-up of the workforce in health crisis countries. It will be looking at the kinds of accelerated resource investments from the North but also from within the poor countries to greatly expand the production of the workforce.

MM: One concern that’s historically been raised about donor involvement in this area is the notion that donors should not support recurrent costs, that items like worker salaries should be handled by domestic resources.

ChenYes and no. I think, for example, the donors have withdrawn from investment and development costs by massively neglecting and under-funding the education and human resource development in almost all these societies for the last 25 years. So it’s not like the donors are only avoiding recurrent costs. They’ve not actually invested, for example, in the educational infrastructure that would train these workers, and that’s why, in part, we have a crisis.

But secondly, I do think that donor funding of recurrent costs is perfectly reasonable if you’re dealing with an emergency and a crisis. If someone is drowning, you can’t say, I won’t throw them a lifeline unless the person can learn how to swim eventually. The HIV/AIDS crisis is a human emergency.

MM: Cuba stands out as a developing country with a very strong health system and positive health outcomes. Is the Cuban model replicable in any way? Or if not, what lessons can be drawn for other contexts?

ChenThe biggest lesson is the very high priority given to health, making large investments, particularly in medical education, and fully employing the labor force — dispersed, assigned and compensated in a solid work environment. You don’t have in Cuba, for example, rural areas that are not adequately covered.

There are clearly elements that are not exportable. The Cuban model is heavily medicalized; it doesn’t have a lot of public health prevention. Prevention is done mostly through politics in Cuba rather than through what we would normally call prevention. So they might have political campaigns against smoking, or for cleaning the streets, something like what China had.

MM: How about the Cuban intensive training and export of doctors and other health professionals?

ChenThe doctors that they train are welcomed and are used in many parts of the world. The countries themselves sometimes pay quite handsomely for these physicians. I think, for example, South Africa pays around $30,000 or $50,000. The money goes to the government, and then that Cuban health worker gets some share of it. There might be in the bilateral government agreement preclusion of the assigned workers from political defection — so political restrictions might be one of the difficulties with that arrangement.

But the doctors sent are very good. They’re motivated, they perform their tasks, they go overseas for a set period of time, and then they go back to Cuba.
MM: But is this intensive training of doctors, beyond even national needs, replicable in other developing countries?

ChenI think it’s possible. It depends on the government’s priorities and whether it is going to make the necessary investment.

By the way, the investment and commitment is not just for medical education, it’s also for universal primary education. That expands the whole feeder stock and enables you to get as many people into the advanced medical education system as you can.

Cuba has demonstrated that once you decide to do this, you can massively expand, and so have other countries.

Iran is another country which had huge worker deficits in the rural areas, but then developed provincial medical schools and massively expanded — to the point where the Iranians are now overproducing.

MM: You’ve been a leader in identifying, articulating and analyzing the problem of the health worker shortfall. What kind of response are you seeing at the global level? Is it commensurate with the problem?

ChenThings are looking better in that recognition is expanding, including in the recent international health partnerships announced by UK Prime Minister Gordon Brown. Addressing the workforce crisis is very much a major feature of that global partnership.

Of course awareness of the problem has been there from the beginning in places like Africa. It was the health ministers of Africa that for three years in a row brought this to the World Health Assembly, insisting that something be done — they were feeling handicapped.

I’m not sure if awareness has grown sufficiently in the economic policy community, which controls the purse strings. And the question now becomes, with that growth in awareness, are you going to have enough financial investment and do you have enough operating capacity and human resources for teaching the teachers? We’re now very much at the testing edge to see whether we can practically make a difference in the countries.

I don’t believe we’ve really yet demonstrated, with the wider recognition, that the realities in the conditions of, say, people with HIV who want access to drugs, have materially changed yet.

MM: Your research and statements suggest that there are immediate steps to be taken to expand the healthcare workforce, but that a real, sustainable change will require investments far beyond those immediate steps.

ChenThere are immediate steps that can be taken that will make a huge difference — good training of community health workers, improving the working environment to retain the existing workers already trained, etc. A much longer steady stream of investments to build an appropriate and effective work force is also needed.

MM: A major fear must be that this issue has its moment in the sun and then gets abandoned, and that the needed long-term commitments do not materialize.

ChenThat is true. The only solace I take is that all of the political rhetoric about global health will be seen as empty unless the healthcare worker problem is taken care of. There are no short cuts. There is no magic bullet or pill that we can take that will solve this. So the issue is going to come back. It’s going to come back every time we say we want to do this, or isn’t it a shame so many people are dying of that.