Introduction: Long-term Croakey readers may remember that the late Professor Gavin Mooney wrote regularly about the inequities arising from wealthy countries “stealing” health professionals, a practice he described as “unethical and unconscionable”. He wrote about the World Health Organization (WHO) raising concerns in 2010 about the flow of health professionals from poor to wealthy countries.
Mooney urged Australia to adopt a medical and nursing workforce plan that resulted in us exporting health professionals to poor countries. As we all know, that has not happened, and workforce shortages and related inequities have only intensified in the wake of COVID.
The Victorian Government is actively recruiting overseas, and announced last August that almost 700 overseas healthcare workers had arrived in the state in the past year from Ireland, Canada, Hong Kong, Singapore, India, New Zealand, the Philippines and the United States. The Queensland Government, meanwhile, is offering hefty incentive payments, of up to $70,000, to attract interstate and international health practitioners.
As one health leader wrote recently, the “bidding war” between jurisdictions risks prioritising one sector or clinical setting over another (for example, hospitals over primary healthcare), and is likely to distort the health workforce and the health system, leading to poorer health outcomes.
The concerns are magnified globally; the recruitment of nurses from poorer nations to high-income countries is “out of control” and affecting health service delivery in countries such as Ghana, the International Council of Nurses told the BBC this week.
In the article below, Susan Brown, the Director of Policy and Advocacy at Women in Global Health, investigates the implications for women in the health workforce.
Her article was first published by an independent journalism publication in Queensland, The Pineapple, under the headline, ‘Pandemic-led exodus of women health workers threatens global health security’.
Susan Brown writes:
In a prominent spot in Brisbane, a billboard looms. It invites Queensland nurses to move to Victoria. The image and invitation front an alarming trend, with implications for local, national and global health security.
I’d seen a similar billboard recently, in Nairobi. Hugging the side of a new airport freeway, the billboard encourages Kenyan health workers to move to Germany. On Facebook, there are dozens of ads asking nurses from Ghana, Philippines, India, Nepal, Malawi, Zimbabwe or Nigeria to move to the UK, offering training, better wages and fast track visas to sweeten the deal. Blogs give tips for how to translate nursing skills from Congolese or Senegalese qualifications to French ones.
While moving overseas to use or deepen professional qualifications or experience or work in a different environment is something many people do, there are consequences which aggregate.
In the case of health and care workers, this trend could lead to a crisis caused by increasingly desperate competition to poach health workers from local services, across state lines or between countries. For low-income countries, where health systems are under-resourced and short of trained health workers, this could be catastrophic.
Prior to the COVID-19 pandemic, the World Health Organization (WHO) had predicted a global shortfall of health workers. In updated figures this year, still using data taken before the pandemic, WHO anticipated a global shortfall of around 10 million health workers.
Women workers
Since the pandemic, health services have lost staff to the virus and long-COVID management and seen an increased drain of staff – mostly women – who are walking away, many due to their pandemic related experiences.
As a woman on Great Keppel Island in Queensland told me recently, her sister, who is a doctor, “is just done”.
“She has nothing left to give any more. She’s left.”
A surgeon I met on a ferry in Norway in July 2022 said she moved to part-time general practice teleconsulting for a health insurance company, as the hospital hours and intensity “had broken her”.
Thousands of similar stories come into my organisation, nurses’ unions and frontline health worker organisations. More than 70 percent of health and care workers and more than 90 percent of frontline health care workers are women.
During the pandemic they faced immense pressure under surge conditions, often with inadequate support and protections. Infection controls like hand cleaner and masks were in short supply in many countries.
Nearly all full body protective suits are designed for men’s bodies and are often purchased in the largest size by health services, meaning it’s hard for women to take care of urination and menstruation needs and keep safe from virus contamination. Unsurprisingly a significant proportion of female health workers got COVID.
Pay and conditions, already a problem in health where women health workers particularly, are underpaid or unpaid, were exacerbated.
Health staff worked extra shifts and the burden of care in the home increased as children had to be home schooled, childcare arrangements collapsed or vulnerable relatives needed support. Women community health workers, generally at the bottom of the health workforce hierarchy, were sent out for essential contact tracing or to deliver COVID vaccines to frustrated, confused or angry people and faced increased violence and abuse.
There are critical gender equity dimensions in the mix, with women health workers already paid 24 percent less than their male counterparts before the pandemic and more often confined to the unpaid and grossly underpaid roles in community outreach.
Men are far more likely to be promoted and already hold around 75 percent of leadership positions. Women, who largely deliver the world’s health services found their perspectives and professional knowledge ignored.
Competition rules
But wait, this gets worse. The resignations or reductions in work hours by health workers in better resourced countries like Australia, coupled with an already existing health worker shortfall, increases pressure on strained systems.
Health services around the world are now in full blown competition, desperately advertising to fill their widening gaps.
And the marketing is crossing borders. As well as health services doing their own direct marketing, other actors have entered the space. Immigration lawyers, universities, human resources companies, coaching services and even conference organisers are working to find doctors, nurses and carers and attract them with promises of training, funding, better salaries and fast-tracked visas for the whole family.
A great migration of health and care workers is underway. It goes from low-income countries (LIC) to high income countries (HIC) and is often associated with colonial pathways due to language and former relationships between countries.
The National Health Service (NHS) in the UK offers salaries five times or more the salary a nurse can get in Nigeria. It isn’t just personal salaries under consideration as there are complexities at play.
Migrant workers from low-income countries send part of their pay home to support relatives. This money, called remittances, adds up to billions in the global GDP and many low-income countries rely on these funds.
For low-income countries, the average value of remittances in their GDP estimated by the World Bank and IMF is around 4.5 percent, but this average hides the fact that in many countries, remittances can range from 10-30 percent of the GDP.
Dozens of low-income countries and their populations face the grim reality of an economic benefit coming if they export their health workers, but the consequences of a severe health and social disadvantages due to the loss of clinical expertise and staff at home.
Nurse Melvis was a Cameroonian carer who moved to the UK to upgrade her training and now works in surgery in the NHS. She offers coaching via social media platforms for other nurses who wish to do the same.
Referring to a news story about 57,000 nurses leaving Nigeria for the UK, US and Saudi Arabia, Nurse Melvis says it means nurses in Nigeria who used to look after 4-10 patients per shift, are now tasked with between 30 to 40 per shift.
Nurse Melvis offered advice to African countries in a You Tube video: “You need to value us and pay us well, otherwise people are going to look for greener pastures.”
Solutions
Fixing this is complex, as there are many variables. A good start would include all governments designing health systems which ensure health workers are adequately paid and there are allocated budgets and resourcing available for surge needs.
This isn’t a simple choice for LICs with the highest burden of disease and very low per capita health budgets. They have high morbidity and mortality from disease considered routine to treat successfully in HICs. They now face the impact of HIC countries underinvesting in their own health worker training and filling the gaps by incentivising LIC workers to move.
Could this be because it’s cheaper for HICs to poach health workers trained by other countries and flout the existence of global arrangements on ethical health worker recruitment?
At the policy level, there should be more focus on training and retention of health workers, including taking a long-term perspective as it can take 10-15 years to train some health workers.
We also need commitments to achieve equal pay and equality in leadership for women and implementation of safe and decent work conditions. We need gender equal health leadership so women who are the experts on health systems can # influence policy and health systems delivery. We need policies to retain women and care for burnt out health workers so we don’t lose them.
If the phenomenon of the great migration of health workers is not recognised and addressed, everyone loses.
Health service users in low and high income countries will face longer waits and less support, remaining health workers will be exhausted, health services won’t be able to staff up for growing needs and will have to deal with competitive tension.
Governments, who hold the responsibility for fulfilling health rights as part of the social contract, will move from handling a temporary crisis such as COVID-19 to crisis mode being standard operating procedure.
That billboard in Brisbane is a sign all right.
Susan Brown is Director of Policy and Advocacy at Women in Global Health. She is from North Queensland and lives in Geneva, Switzerland
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