Washington DC/ Chapel Hill, North Carolina/ Geneva — Health services don't deliver themselves. It is the nurse who triages in the emergency department, the midwife who delivers babies and cares for mothers, the community health worker who gives babies vaccines, the care assistant who bathes someone at home, the surgeon who performs the operation, the anesthetist who blocks the pain, the pharmacist who matches the script to the medication, and the physiotherapist who restores movement.
With Universal Health Coverage Day (December 12) just behind us, it is critical to recognize the contribution of health workers, most of whom are women, and call for political leaders to urgently recognize and address the escalating resignations, shortfalls, and staff movements putting health security at all levels, from local to global at risk.
Listening to organizations who represent frontline health workers, community health workers, nurses, family doctors, and health professionals, we hear that after nearly three years of a pandemic there is worker burnout, staff shortages, migration of health workers, increasing reports of danger and violence at work, and rising mental health concerns.
Taken together, there are four alarming trends currently affecting health workers' ability to deliver health services for all and hindering our advancement towards UHC.
Global shortage of health workers
WHO figures released in April this year estimated a projected global shortage of 10 million health workers in 2030 based on current trends (mostly depicting a pre-COVID-19 situation). Since then, in the US alone, the US Bureau of Labor Statistics now estimates that more than 200,000 registered nurse positions are projected to be vacant annually over the next decade and WHO points out the largest shortages will be in Africa and Southeast Asia.
Globally, burnout levels among doctors and nurses have been estimated at 66 percent, a figure that doesn't bode well for future health worker retention or indeed the ability to attract new recruits. Lack of available health workers, particularly in the global south where disease burden is higher, was the biggest obstacle to maintaining health services and delivering vaccines during COVID-19, according to WHO.
Protection of health workers
The pandemic stretched already understaffed and under-resourced health systems, increasing pressure and danger. Too often women were issued medical personal protective equipment (PPE) designed for male bodies that left them at risk. Health workers were sent door-to-door to enforce lockdowns or do contact tracing or give vaccines with no added protection, facing angry, confused, or frightened people.
They worked extra shifts under horrendous conditions, many with little or no extra pay. It is no wonder that the International Council of Nurses described the COVID-19 effect as a "mass traumatization of the world's nurses." The average prevalence of PTSD among global health workers is estimated to be around 17 percent, but this figure is much higher for women frontline workers, at 31 percent.
Advocates for health equity have a responsibility too, to bring the same passion that we see, for instance, in the global struggle for access to COVID vaccines, to the cause of equity and fairness for health workers who deliver these vaccines.
The problem of pay
A June 2022 Women in Global Health report estimated that upwards of six million women health workers worldwide were either underpaid or not paid at all despite working in core health system roles. Just 14 percent of community health workers on the African continent are salaried. WHO figures reveal that women earn 24 percent less than men doing the same job.
Women are disadvantaged in promotions too: despite 70 percent of health workers and 90 percent of frontline health workers being women, men hold around three quarters of the leadership positions. Historically female professions, like nursing and midwifery, have workers of all genders but they face difficulties advancing into leadership positions due to historical biases against them as caring and nurturing professions, where they are not seen as leaders.
The "Great Resignation" in health
Unsurprisingly, there is a Great Resignation in health-worldwide we see a flood of women health professionals who are planning to or have already left their jobs. In the summer of 2021, in the UK alone, more than 27,000 staff voluntarily resigned from the NHS amid burnout caused by a combination of pandemic pressures and staff shortages. In Ghana, most health workers experienced high levels of stress (68 percent) and burnout (67 percent) citing lack of preparedness as a key factor.
A billboard on a Nairobi freeway advertises for nurses to move to Germany. On Facebook pages, we find hundreds of advertisements for health workers to move to the UK. The incentive for international moves is fast-track visas and better pay. And why wouldn't health workers give serious consideration to moving somewhere with better pay or more training or the chance to earn enough to send money back to their families?
There are serious implications as nurses from low-income countries leave their health systems to prop up others in wealthier countries that have failed to train health workers of their own. It is estimated that this Great Migration of health workers costs LMICs an estimated $15.85 billion annually in excess mortality.
While any individual has the right to migrate freely, recruiting companies actively recruit nurses while violating the Global Code of Practice on International Recruitment of Health Personnel, further exacerbating health worker shortages in areas that need health workers most.
Africa has only four percent of all health workers in the world, but more than 50 percent of the 10 million health workforce shortage is in Africa. With the Great Resignation and the Great Migration, these are serious concerns and were pointed out by Heads of State at the U.S.-Africa Leader's Summit last week.
Universal health coverage should not just be about individuals and communities getting better and more affordable health services, it should also be about recognising health workers, their roles, and their needs. Health workers need safe working environments free of violence and harassment that give them all the resources they need to do their jobs well.
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Appreciation isn't just about applause. It's about governments, which are responsible for the health of their citizens, ensuring systems are properly resourced-from hospitals to home aid. From guaranteeing equity in pay to properly paid work. From provision of proper PPE to safety at work in all conditions. And making sure that career choices and promotions are open to all, regardless of gender.
If global leaders are serious, then it's time they do more, as they have promised, and accelerate their efforts to achieve universal health coverage and the 2030 Agenda for Sustainable Development. The Working for Health 2022-2030 Action Plan sets out how countries can support each other to build and strengthen their health and care workforce.
Our overburdened health workers have signaled that they have had enough. They have continued to protect us despite the shortages, lack of protection and problems related to pay, but they are burnt out. It is time we moved from applause to action and begin finally, to address the known problems plaguing global health systems.
Dr. Roopa Dhatt is Executive Director and Co-Founder of Women in Global Health (Washington, DC); David Bryden is Director of Frontline Health Workers Coalition and Senior Policy and Advocacy Advisor at IntraHealth International (Chapel Hill, NC.); Dr. Gill Adynski is Nursing and Health Policy Analyst at the International Council of Nurses (Geneva, Switzerland).
IPS UN Bureau
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