Can We Afford Fewer Health Workers?
Two Harvard researchers (Thomas Bossert and Tomoko Ono) recently published a paper proposing that the World Health Organization reduce its recommended target for health workers in each country, which is 2.3 health workers per 1,000 people. The US, by the way, has about 13 health workers per 1,000.
The researchers claim it's "unrealistic as a short- or medium-term goal for many of the low- and middle-income countries" to try to achieve this target, as it would be too costly or just too hard to train and employ so many doctors, nurses and midwives.
The 2.3 per 1,000 figure emerged from research conducted by the Joint Learning Initiative, which plotted country performance on two measures: births attended by a midwife or other health professional, and measles immunization by age one year. Researchers found countries needed at least 2.3 health workers per thousand to get reasonably decent coverage (~80%) on those two measures.
By that measure, the WHO estimated a worldwide shortage of more than 4 million health workers. Others have reported 57 countries have workforce shortages using the 2.3 standard. On average, each of the 57 countries needs another 75,000 health workers. The WHO also estimated it would cost $136 million a year for each of the 57 countries to train enough people to keep up with the ratio, and another $311 million per country per year to keep those people employed.
That's an unrealistic target, say Bossert and Ono.
In one way, they are right. If countries have limited budgets, and they want to achieve a higher health status for their population, spending money on health care may not be the most efficient way to achieve health. While Bossert and Ono don't suggest this, countries with very scarce dollars could consider focusing those resources on education as a top priority, since education is an important determinant of health.
But that's not the authors' point, however. They are instead arguing that if countries can't afford more health workers, they should just make do with less, since external support from donors to pay for or top up salaries is still not likely to be enough, and "relying on donors to cover salaries over the long term is generally not considered prudent."
But setting goals based on what countries can afford rather than what they need will never get us to "health for all," or even "health for most."
So how do we meet the needs-based WHO recommendation considering the financial limitations of so many countries?
It's time we viewed health as a critical worldwide public good for which each country has shared responsibility. There are some things we could do.
- The US should develop policies that restrict recruiting health workers from shortage countries, in line with the recently passed WHO Code of Practice for the International Recruitment of Health Personnel.
- Remove harmful macroeconomic policies such as wage caps that restrict how much governments can spend on salaries for health workers and teachers. (To their credit, Bossert and Ono do mention these constraints in their article.)
- Develop long-term funding streams on which developing country governments can rely so they can budget for more training and salaries for health workers. Many countries may need support for decades, and we should recognize that supporting the health workforce and health system will get us to a point of self-sufficiency more quickly than undercutting them.
- Explore strategies such as task-shifting that would allow lower-level (and less expensive) cadres of workers to provide certain health services as long as quality is equivalent to what higher-level workers provide. See for instance our own Barrot Lambdin's blog post on health workforce strategies from the International AIDS Conference in Vienna last week.
Wouldn't it be great if we could commit to getting all countries to at least 2.3 health workers per 1,000, rather than setting our sights -- and health outcomes -- lower because we don't think the money is there?
Leave a Reply