Medical staff treat a Covid-19 patient at a hospital in Lodi, near Milan, Italy
Demand for healthcare workers exceeded supply long before the pandemic struck © Emanuele Cremaschi/Getty Images

When Silvia, a 33-year-old Italian nurse, received a bonus worth less than €500 after months battling one of Europe’s worst coronavirus outbreaks, she wondered if it “was a joke”.

She had worked on a busy Covid-19 ward of a hospital in the city of Genoa throughout the crisis, putting her health on the line and missing out on time with her young daughter “from a sense of duty and love for the job”.

The one-off bonus from the Italian health ministry announced late last year was “almost insulting for those of us who had spent months on the frontline risking our lives”, said Silvia, who declined to give her full name.

Silvia’s disillusionment points to the scale of the challenge for pandemic-hit governments around the world as they grapple with the question of how, and whether, to reward staff who endured the most searing experience of their professional lives. 

In many cases, the discussions have forced governments to acknowledge longstanding grievances from healthcare workers about their pay and conditions. The ability to retain and recruit staff will also play a vital role in determining how strongly not just health systems, but national economies, emerge from the crisis.

Scatter plot showing the remuneration of nurses, 2017 or nearest year

Chris James, senior OECD health economist, said the focus had already shifted from worries over the availability of hospital beds and ventilators in the early phase of the pandemic to anxieties over staffing levels.

“Moving forward, one of the big discussion points among OECD countries is how do we make sure health systems can be stronger in future waves of Covid and meet any other emerging threat,” he said. “The health workforce is at the centre of that.” 

Demand for healthcare workers exceeded supply long before the pandemic struck, said Anita Charlesworth, chief economist for the Health Foundation, a UK-based charity. This was fuelled by a global commitment to achieve universal health coverage and the rapid spread of diseases such as cancer and diabetes as nations industrialise and prosper. 

Charlesworth pointed to a World Health Organization estimate that Europe would have a shortfall of 1.5m nurses by the end of the decade. The global estimate would be 13.5m. “If we’re going to be more resistant to the shocks of emerging infectious diseases we’re going to need a bigger buffer,” she said.

A survey published in September by the European Observatory on Health Systems and Policies, an intergovernmental group, found roughly half the countries polled had offered some form of financial recognition to staff for their contribution during the first phase of the crisis.

In Italy, up to August 2020 about €9bn had been allocated to the health sector, of which about €2bn was earmarked for healthcare workers, including recruitment, overtime and bonuses. The German government announced in October that €100m would be made available for bonuses, principally for hospital staff.

In some countries, debate over how to reward healthcare workers for the rigours of the pandemic has crystallised enduring complaints about healthcare workers’ remuneration, adding pressure on governments to act. 

Angèle Malâtre-Lansac, associate director for health policy at the Institut Montaigne, a French think-tank, said the public acclaim for the country’s nursing staff had thrown into sharp relief how poorly they were paid. “France is one of the few OECD countries where nurses’ pay is below the average salary for the population,” she said. 

President Emmanuel Macron’s government spent almost two months negotiating with trade unions after the first wave of the pandemic, eventually striking a deal that delivered bonuses for health and long-term care staff.

Grouped bar chart showing the number of healthcare workers per 1,000 people (2017 or latest year) for doctors and nurses in various countries

Other employees, including nurses, paramedics, technicians and administrative staff, also received a €183 a month pay boost. The changes cost €7.6bn, part of an €8.2bn a year package to raise recruitment and retention that also included additional allowances for doctors.

But the attempt to address under-investment in the French health system has not proved a panacea. “I’d say dissatisfaction at hospitals remains very strong,” Malâtre-Lansac said. “The impression many have is that France doesn’t value hospitals enough and is always trying to reduce resources.”

In the UK, where NHS pay has failed to keep pace with inflation over a decade of fiscal austerity, a government proposal to give staff a 1 per cent pay rise sparked widespread anger. The devolved government in Scotland is planning a 4 per cent pay award. 

Amanda Smith, an intensive care nurse in Northern Ireland and a Royal College of Nursing representative, said several ICU colleagues felt so exhausted by the crisis that they had decamped to less pressured fields such as midwifery and health visiting. “I feel absolutely burnt out . . . I think I’ll stay in nursing but maybe not in ICU,” she said.

Such accounts should give pause to governments and health leaders, said Sarah Reed, a senior fellow at the Nuffield Trust, a UK think-tank, who has studied international responses to the pandemic.

“Given the extreme stress that staff have endured throughout the crisis . . . it’s just a real fear for a lot of health systems: how will they retain the workforce they need and grow their staff supply to be able to fully bounce back?”


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