Top Ten Myths about the Global Health Workforce Crisis Busted
Myth #1: It's mainly a numbers problem
Actually the main problem is maldistribution of health workers: rural/urban, primary care/specialty.
Myth #2: Health worker migration has no victims
Migration not only deprives the poorest countries of the health workers who migrate, but since the most qualified workers are the ones who migrate, it impairs countries’ ability to train replacements. A high percentage of the global health diaspora were professors in their home countries.
Myth #3: Developing-country health workers aren’t paid enough
Health workers are consistently in the top wage earners in their countries and have little or no student loan burden. Their standard of living, although not the same as Organization for Economic Co-operation and Development physicians, is extremely high compared to their fellow citizens.
Myth #4: Foreign-trained health workers are more likely to work in rural areas in the US
After their required service, foreign-trained health workers are more likely to work in major metropolitan areas than US trained workers.
Myth #5: No one wants to be a nurse
Nursing schools around the world are consistently oversubscribed with applicants. Admissions criteria need to be made evidence-based to produce nurses more willing to work in urban and other underserved areas.
Myth #6: There is a medical and nursing faculty shortage
In many countries criteria to be faculty are not aligned with country realities and are more geared toward research than service to reduce health disparities.
Myth #7: Recruiting rural youth will “dumb down” nursing and medicine
The Training for Health Equity Network of community-based medical schools has considerable evidence that rural students perform as well or better as their wealthy urban counterparts. Governments have an obligation to meet the health needs of all their residents, not just urban ones.
Myth #8: Quality of training is the main problem
Access is the main problem. Most excess mortality in developing countries is due to relatively easily prevented and treated conditions such as vaccine preventable diseases, diarrhea, malnutrition, and malaria. Most health workers already have the knowledge and skills to effectively address these conditions. Research by Serneels and others have revealed a significant “Know/Do” gap in health worker performance. When tested they know proper diagnosis and treatment, but when caring for patients, they don’t carry out what they know. Improved work conditions and supportive supervision, not longer training, is needed to improve performance.
Myth #9: Doctors are the natural leaders of health systems
Although physicians do represent the top of the clinical knowledge pyramid, leadership can come from anyone with a strong vision of how to cost-effectively reduce health disparities and reach the Millennium Development Goals.
Myth #10: All health worker policy is made by central governments
The rubber hits the road in health professional schools, and most schools have incredible flexibility to alter their curricula, clinical teaching sites, and enrollment. Local governments often have development funds that can be used to expand or establish health professional schools.
Recently, I presented this Top Ten at the National Physicians Alliance (NPA) Annual Meeting in California. The NPA is a 20,000 members strong group of physicians dedicated to improving access to quality health care. Interest in the global health workforce crisis was strong, with many of the attendees expressing dismay that they had not previously been aware of the global and domestic health worker crisis, its causes, and solutions. Those who had been aware of the crisis had not been aware of its magnitude or the effects that the migration of health workers had on the health of vulnerable populations in developing countries. Many were not aware that many of the solutions to the crisis could be implemented locally.
In addition to the Top Ten, other notable practitioners in the field shared their perspectives on the global health worker shortage.
Amy Hagopian from the University of Washington, Seattle, set the stage with her talk on the situation in developing countries and push/pull issues leading to immigration. She presented that internal migration was also occurring within countries, especially from Ministry of Health jobs to jobs in the private sector. The problem has become so great that a code of conduct has been written by the NGO community to ensure that their hiring practices do not damage national health systems. Hagopian noted that 60% of foreign-trained doctors practicing in the US are from low-income countries. The largest populations of foreign-trained doctors in the US are in the major metropolitan areas of Chicago, Los Angeles, New York City, and Miami, rather than rural or underserved communities. She offered a ray of hope in presenting the developed countries that have taken strong steps to become self-sufficient in health workers. Canada has recently increased its nursing supply by 60% while Norway has made a national commitment to health workforce self-sufficiency.
Ellen Shaffer from the Center for Policy Analysis on Trade and Health presented trade-related issues, including how trade treaties and the World Trade Organization affect the global licensing of health professionals. For example, Indian physicians, unlicensed in the US, are giving preliminary readings of x-rays on patients in US hospitals. Shaffer stated that free trade agreements view regulations such as health worker licensing as a barrier to trade and work to remove them. In Europe the Bologna Process will make all health science degrees in Europe mutually recognized within Europe (e.g., a physician’s degree from Poland will be recognized as equal to a physician’s degree from the UK). This is expected to increase flow of health workers from poorer countries like Poland to wealthier counties like the UK and exacerbate existing inequalities in health worker distribution and access to care.
Richard Scheffler presented an economist’s view of the US physician shortage and presented data from his book Is There a Doctor in the House? He recommended creating more incentives for physicians to enter primary care and serve underserved populations. Scheffler presented data that when the US is motivated to increase health worker production, it can do so easily. During World War II, the Accelerated Program doubled American medical school enrollment. He also predicts that the US can gain significant efficiencies in health service delivery by training more mid-level providers such as nurse practitioners and physicians’ assistants. The number of nonphysician health workers per physician in the US is only 14, much lower than other countries, showing that the US has opportunities to maximize task shifting and take a team approach to delivering health care.
With the passage of comprehensive health reform in the US and the anticipated coverage of 32 million currently uninsured Americans and the accompanying increase in demand for health workers, the US’s role in the global health workforce is becoming more apparent. As we advocate for a resolution to the global health workforce crisis, it is important that we build constituencies in developed countries as well as in Geneva and developing countries.