What is the cure for the global healthcare worker shortage?

Even before the onset of Covid-19 universal healthcare services all over the world were facing an uncertain future because of critical imbalances between the demand and supply of essential frontline healthcare workers. Although the global pandemic has exacerbated the situation, structural problems such as a lack of long-term workforce planning, poor retention, the international mobility of health workers and retirement from an ageing workforce all pre-date it.

“For far too long, the health sector has been sidelined in discussions on health workforce mobility, despite the significant impact this mobility has had, and continues to have, in low- and middle-income countries globally,” explained Dr Khetrapal Singh, World Health Organization (WHO) Regional Director for South-East Asia at a tri-regional meeting in June that set out to address the challenges related to the international mobility of health professionals, especially during the Covid-19 pandemic.

Around 30 per cent of all foreign-born or foreign-trained doctors or nurses working in OECD countries originate from lower-middle and low-income countries and account for three to six per cent of all migrant doctors and nurses. In the US, for example, more than 2.6 million immigrants, including 314,000 refugees, were employed as healthcare workers in 2018, representing 28 per cent of physicians, 24 per cent of dentists and 38 per cent of home health aides.

As Dr Mark Britnell, KPMG’s Global Chairman for Healthcare, Government & Infrastructure, explained in his 2019 book Human: Solving the Global Workforce Crisis in Healthcare, the scale of the problem was recognised in 2017 at the Fourth Global Forum on Human Resources for Health.

“The Dublin Declaration on Human Resources for Health said we will need around 40 million more healthcare workers by 2030, but we are in danger of being 18 million short,” writes Dr Britnell. “That’s more than one in five of the 80 million we will need.”

Long associated with the export of trained healthcare workers and the principal source of migrant nurses across the OECD, the Philippines’ long-standing nursing brain drain — driven by low pay and poor working conditions at home and the demand for Filipino nursing acumen overseas — has now become a full-blown crisis.

Between January and August 2021, nearly 7,000 Filipino nurses left the country, many following a well-trodden path to the US and the UK. The Philippines is the largest supplier of foreign-born Registered Nurses (RN) in the US, where they represent five per cent of the RNs in the country. In the UK, which had one of the highest levels of foreign-born nurses in the EU before Brexit, Filipino nurses represent 27 per cent of the nursing staff.

In the same month, the Private Hospitals Association of the Philippines (PHAPi) estimated that 40 per cent of the nurses working in the private sector, where pay and conditions are deemed to be worse than in the public sector, had resigned in 2020.

Jonas Elmer Balneg has both a professional and personal perspective on the challenges facing nurses in the Philippines and the undoubted appeals of migration. A Charge Nurse at The Philippine General Hospita, Balneg has been working on the frontline of the fight against the pandemic since the very outset.

“The Philippines has had the longest duration of lockdown in the world, and this pandemic has exposed the weakness of our healthcare system,” says the 32-year-old. “I don’t blame nurses for seeking work abroad, because the compensation is so much better.”

Having worked in the Philippine health system for a decade, Balneg recognises that his occupation’s challenges are systemic. As the son of a nurse who spent 38 years supporting her family by working in the Arabian Gulf, he understands the draw of foreign employment. “I saw the sacrifices my mother made, so I thought that maybe I could do it too,” he says.

As an employee in the public sector with few family commitments, Balneg insists that he is sufficiently compensated, but admits that he is also driven by a sense of responsibility to his fellow professionals. “As I am blessed enough to be able to live my life as it is, then I think it would benefit the hospital and the country if I stayed here,” he says with a smile.

The scale of the healthcare workforce crisis in the Philippines has recently reached a new pitch with nurses taking to the streets of the capital, Manila, threatening more mass resignations and industrial action while also demanding the payment of risk allowances, hazard pay and political changes.

In its State of the World’s Nursing 2020 report, the WHO predicts that, without action, the projected shortfall of nurses will be 249,843 in the Philippines by 2030 unless greater investment is made now to retain them.

So, what can be done to address the needs, not just of Filipino nurses, but of healthcare workers the world over, especially in lower- and middle-income countries?

“Countries experiencing excessive losses of their nursing workforce through out-migration should consider mitigating measures and retention packages, such as improving salaries (and pay equity) and working conditions, creating professional development opportunities and allowing nurses to work to their full scope of education and training,” says the report, which is the first of its kind to be issued by the WHO.

The investment required to fund the 5.9 million additional nurses that the world needs equates to US$10 per capita in low- and middle-income countries according to the WHO. This level of funding will require public and private sector innovation.

When looking to support the next generation of nurses, new efforts are showing promise in addressing challenges. The cost of education needed to become a health worker, for example, can deter students from pursuing a career in health care. Taking this issue on, in the Philippines, InvestEd’s "Frontliners First: Nurse Education Loan Program" provides college students in need with loans to fund their nurse education, as well as coaching and mentoring to help them achieve success after graduation. In Indonesia, DANAdidik, a peer-to-peer crowdfunding platform, offers interest-free micro-loans worth up to US$770 to students who repay supporters upon graduation, thus making a career in healthcare less of a financial burden.

As well being able to envisage a financial pathway through their initial education and training, nurses also need to have their voices heard, nurse Balneg insists, especially when it comes to policy and decision-making issues that affect recruitment, retention and training.

“I do not think I can make a difference individually,” he admits. “But maybe, through the development of certain protocols or new policies, I might be able to make a small step in helping to change the future for nurses in the Philippines.”