the nursing shortage is increasing at an alarming rate.
In Zambia, 27 of every 1,000 health care workers die of HIV/AIDS. In the
United States, without intervention, the nursing shortage will reach 1 million
by 2012. In Uganda, there are on average only one or two nurses for every
100 patients. Canada's nursing shortage is expected to reach 113,000
Certainly migration of health care workers from poor to wealthier countries that offer better pay and working conditions contributes to the shortage in many developing countries. But what causes shortages in wealthier nations? The reasons are not totally clear-cut, and neither are possible solutions to the global shortage, according to participants of the 2006 Global Government Health Partners Forum held in November.
The conference, hosted by the nursing school's Lillian Carter Center for International Nursing (LCCIN) and secretariat for the biennial conference, brought together chief nursing officers (CNOs) and chief medical officers (CMOs) from 107 countries to address national and international nursing workforce issues. During the forum, participants examined workforce roles and responsibilities and models of collaboration based on current scientific findings, shared lessons learned, and developed partnership strategies to enhance their response to public health crises. The CNO/CMO dyads from each country collaborated to develop a statement of priorities and a plan of action to address challenges in their own countries.
The conference built on the successes of the 2001 and 2004 meetings involving CNOs who developed their leadership skills and built bridges with one another to address common nursing issues. The landmark 2001 conference marked the first time many CNOs met their regional counterparts and heard from nursing association and government leaders, while the 2004 forum was the first of its kind to bring together CNOs and CMOs in a collaborative, partnership-building effort.
"The value of the forum extends beyond health leaders detailing the myriad forces challenging today's health systems," says Dr. Marla Salmon, secretariat co-chair, dean of the nursing school,and LCCIN director. "It helped these senior government health leaders formulate plans to address the challenges and at the same time create manageable action plans to positively influence the push-pull factors, such as work conditions, in their own countries and regions."
from Brazil, Bahrain, and Barbados each worked on a plan to address human
resources in their countries.
Workforce migration begins within countries as health care workers move from rural to urban areas and then from the public to the private health sector. Then the pattern shifts from developing countries to industrialized ones. The effects of such migration on many regions are both profound and frustrating. Africa, for example, carries 25% of the world's burden of disease but has only 1.3% of the world's health workers. In Nigeria, 18% of the country's doctors are abroad, and there are more Malawian doctors in Manchester, England, than in Malawi itself. After Africa, South America and the Middle East face the next highest shortage of health care workers, particularly nurses.
"The full magnitude and impact of the global shortage of health workers is more evident than ever before," says Dean Salmon. "The crisis cuts across all sectors of health care with critical shortages of nurses, as well as doctors. Collaboration within and across the sectors is imperative in today's world."
Many countries are seeking ways to retain nurses in regions like these, where the nurses who remain behind are the ones who bear the brunt of the day-to-day hardships brought on by such shortages.
Dr. Manuel Dayrit of the World Health Organization (WHO) told attendees that in countries where the education of nurses is subsidized by government funds, the government loses its investment when these nurses migrate. "Use of tax income to fund nurses' training does not provide a good return on investment in countries whose graduates migrate to another country because when they leave the government loses its investment," he said. The Philippines, by contrast, which has a large private sector to provide nursing education, produces thousands of nurses, many of whom migrate. In this instance, while there may be no direct loss of government investment, the loss of health professionals from migration affects the health system in other ways.
Other developing countries, like Malawi, are using foreign aid (from Great Britain in this case) to raise the salaries of health care workers. But countries don't always have discretion in spending these kinds of resources. Dr. Wilmer Beteta Lopez, Nicaragua's CMO, said the international loan agreement he works under does not allow him to adjust salary levels for nurses in more expensive regions of his country, making retention especially difficult in those areas.
While salary is extremely important, it is not the only issue that drives nurses even in the poorest countries to migrate or to leave the health workforce entirely, according to one presenter's research. Barbara Stillwell is a senior technical adviser with Liverpool Associates in Tropical Health and runs a project funded by the U.S. Agency for International Development to build capacity of the health care workforce worldwide. She studied nurses in Uganda and found fewer than half of those interviewed said they were satisfied with their jobs. While satisfaction with their salary was the most common complaint, nurses also wanted
to feel valued.
"People find motivation through their workplace relationships," she said. "Providing motivation is not necessarily expensive, but you must have management in place to do that. Feeling valued will influence productivity, performance, and also retention." Her study found nurses stayed on the job when their workload was more manageable, when they actively participated in creating a better health care facility, and when they were recognized for good work.
|WHO has declared 2006-2016 the Human Resources for Health Development Decade to bring attention to human resources for health. The strategic window will not last forever|
—Marilyn Lorenzo, Professor, University of the Philippines, Manila
the push-pull effect
Though some developing countries are trying to improve salaries and working conditions to keep nurses in-country, they are hampered by what they cannot control: nursing shortages in developed countries. Shortages in developed countries trigger a push-pull effect. Poor conditions push nurses out of their home country, while developed countries pull migrant nurses in to fill their own shortages. For many conference participants, the question was, "Would nursing migration be an issue if there were no shortages in developed countries?"
Part of the solution to the push-pull effect lies in developing cooperative efforts by those countries on the pulling side of the equation.
When Great Britain, for example, infused funding into its national health care system in 2000, its leaders recognized the top goal was to make the country more self-sufficient in terms of its workforce. Health care leaders began working on long-term plans to draw British nurses back into nursing and to attract new ones into the profession by fostering a better image of the country's department of health. To address short-term needs, they decided to recruit internationally, though only as a temporary measure, says Debbie Mellor, director of workforce capacity for the country's department of health. "We were very concerned if we were going to increase international recruitment that it be done ethically," she says.
They developed a voluntary code that independent providers and recruiters had to sign if they wanted to work with the National Health Service. The code included a list of "no-recruit" countries where workforce shortages were especially grave. The code specified that nurses could be imported from the Philippines and South Africa, with specific memos of understanding signed with these countries.
"Our experience in the U.K. is that partnerships can reduce the push and pull factor," Mellor said. "The bilateral agreements and programs of cooperation have been very useful and a helpful way for us to make sure that we're proceeding in an ethical way."
While international recruitment was under way, the department also expanded its number of training locations and promoted the National Health Service as a model employer in a public campaign. A new, fairer pay strategy was implemented, and child care needs of the nursing workforce were addressed, as were issues of violence and harassment in the workplace.
"We had an 80% increase in U.K. nurses coming out of training and had less of a need to rely on international recruitment," Mellor said. "All of us in our health systems should be aiming for greater self-sufficiency."
Likewise, the Philippines began addressing its nursing shortage in a strategic way, said nursing professor Marilyn Lorenzo, of the University of the Philippines at Manila. While that country's leaders were in the process of long-term planning for human resources in health care, she came forward with data showing inadequate standards and salary inequity among health care workers throughout the country. The Philippine master plan for Human Resources for Health now addresses national competency standards, the promotion of ethical recruitment, and salary increases, and government nursing positions now outpace those in the private sector. She told conference attendees that the next step is to organize a network to implement the plan more broadly, which over the next five years is expected to result in an increase of health care workers working in underserved areas.
As countries like Great Britain heed the call to action to fill their own vacancies, poorer countries may get some relief from international recruitment. And there are other positive changes as well, according to Mireille Kingma, of the International Council of Nurses. Some studies suggest that workers on average return to their home country after five years. Additionally, job opportunities are improving worldwide, especially for women.
But real change in migration flows, Kingma said, will happen when poor countries achieve benchmarks of development, such as clean water, lowered infant and maternal mortality, and a thriving economy. In that way, regardless of what happens in wealthy countries, developing countries can start down the path to a self-sufficient workforce.