|Year : 2022 | Volume
| Issue : 2 | Page : 47-51
Human resources for health migration and health inequality in the commonwealth of nations
Olumuyiwa Odusanya1, Funmilade Adepoju2
1 Department of Community Health and Primary Health Care, Lagos State University College of Medicine, Ikeja, Nigeria
2 Department of Community Health and Primary Health Care, Lagos State University Teaching Hospital, Ikeja, Nigeria
|Date of Submission||11-Jul-2022|
|Date of Decision||27-Jul-2022|
|Date of Acceptance||02-Aug-2022|
|Date of Web Publication||27-Dec-2022|
Department of Community Health and Primary Health Care, Lagos State University College of Medicine, Ikeja
Source of Support: None, Conflict of Interest: None
Human resources for health (HRH) migration is a growing problem globally. Most of the migration is from the low and middle-income (source) countries where the HRH density is low to the more affluent (destination) nations. Poor career pathways, limited opportunities for growth and development, poor compensation, and socio-economic challenges are the main reasons for migration. The effects manifest as health inequalities with a lower density of HRH, and poorer health indices including lower life expectancy in the source countries making the achievement of the third sustainable development goal (SDG3) very challenging. The world has the tools in various codes and resolutions needed to tackle HRH migration but the political commitment to faithfully implement them is lacking. Solving HRH migration requires a holistic approach with collaboration and commitment between both source and destination countries and should be based on the principles of transparency, fairness, and mutual benefits. Each nation should urgently commit to producing adequate numbers of HRH to meet the health needs of its people, retain them, and reduce dependence on foreign-trained HRH.
Keywords: Health inequalities, health systems, human resources for health, migration, solutions, statistics
|How to cite this article:|
Odusanya O, Adepoju F. Human resources for health migration and health inequality in the commonwealth of nations. J Niger Acad Med 2022;1:47-51
|How to cite this URL:|
Odusanya O, Adepoju F. Human resources for health migration and health inequality in the commonwealth of nations. J Niger Acad Med [serial online] 2022 [cited 2023 Mar 30];1:47-51. Available from: http://www.jnam.com/text.asp?2022/1/2/47/365601
| Introduction|| |
Health as defined by the World Health Organization (WHO) is a complete state of physical, mental, and social well-being and not just the absence of disease or infirmity. Promoting wellness and increasing the quality of life is a key outcome of public health as defined by a notable public health expert over 100 years ago. Health must be seen as a resource for living and not as an end in itself. The central role of health and wellbeing in human development is now well recognised. The Alma Ata declaration sees primary health care (PHC) as a central and essential element in the overall socio-economic development of nations. This is confirmed further in the Sustainable Development Goals (SDG), where the third goal is on health with several set goals and targets which if achieved will enable the greatest number of people to achieve the highest quality of health. Moreover, health is a critical component of human security and development.
Health systems refer to the totality of organizations, and resources whose primary goal is to improve health. Adequate staffing levels, funding, supplies, and governance are all needed for health systems to function properly. The WHO has published a six-building framework that enables the understanding and evaluation of health systems. The building blocks are human resources for health (HRH); service delivery; medicines, vaccines, and technology; health information; health financing; leadership and governance.
The human resources for health (HRH) consist of both “core “or clinical staff (doctors, nurses, pharmacists, laboratory scientists, and community health workers) and non-clinical staff (managers, health economists, accountants) who work together to deliver health services to the people. HRH may be further classified as formal or orthodox who are trained in accredited and licensed institutions such as universities, medical colleges, and schools of nursing, and the traditional or informal whose training is largely personalized and is not easy to standardize in terms of knowledge and competencies. The focus of the paper is on the formally trained HRH.
It must be recognized that a larger part of the training of the clinical staff is uniform globally. This is without prejudice to the intercountry and regional variability and requirements. This is due in part to the universal nature of the human being in both disease and health. There is reciprocity and recognition of training obtained in most countries from accredited training institutions such that health graduates do not start fresh training but rather are required to show the same levels of knowledge skills and competencies as health workers in their migrant country through licensing or board examinations to ensure safety and quality of care amongst other reasons.
Therefore, it can then be postulated that countries that for some reasons are not able to retain their health workers are pushing them into a free global market or aiding them involuntarily to migrate. There are questions of morality for the developed world as they poach health workers from the less developed world. But it is a free market determined by societal expectations, desired quality of life by the health graduates, socio-economic opportunities, better career paths, opportunities to acquire better skills, and training (these are the so-called “push factors”) that make it possible for HRH to migrate. It is almost impossible by law or decree to limit the movement of HRH. In addition, it will appear citizens of the developed world are not as interested or attracted to the health sciences for many reasons creating a gap in the numbers of the HRH required which is readily filled by the pool of migrant health workers. Even in developing countries, the number of young persons interested in the health sciences is dwindling partly because the prospects are not as bright as in the entertainment, and sports industries.
The Commonwealth of Nations is a political association of 56 member states with the recent inclusion of Togo and Gabon, almost all of which were former colonies of Britain and has a population of 2.5 billion. The countries exist in Africa (21), Asia (8), the Americas, Europe (3), the Caribbean, the Americas (13 and the Pacific (11). Thirty-two of these states are classified as vulnerable states. The objectives of the paper are to discuss HRH migration, and its impact and proffer solutions to the crisis of human resources for health (HRH) in the Commonwealth of Nations.
HRH migration statistics
HRH move universally although the flow is more from the global south (source countries) to the north (destination countries). The exact number of HRH migrating is unknown due to some challenges. There is no comprehensive or complete database on HRH migration. Part of the challenge for example is correctly classifying a health worker of African origin who trained in the United Kingdom (UK) or UK-born HRH who trained in a foreign country. The more conservative approach though not without its limitations is to examine the data based on country of birth or country where the first professional qualification was obtained. It is known that up to 15% of HRH practice outside their county of birth or where they obtained their first professional qualification.Furthermore, the number of foreign-trained HRH in six high-density Organisation for Economic Cooperation and Development (OECD) countries rose from 32% to 36% between 2012 and 2016 while up to 70% of HRH in six high-density Gulf countries were from other nations.
The main destination countries according to OECD data are the United States of America (USA), the UK, and Canada. Almost half of the HRH migrating are from Asia (mainly from India) followed by Africa (led largely by Nigeria). As of March 2022, 7,256 Nigerian trained nurses were on the permanent register of the UK Nursing and Midwifery Council, an increase of 2,946 within twelve months from March 22021 to March 2022. The numbers of nurses migrating from Nigeria showed a steady and sharp increase between March 2018 to March. 2022 The UK General Medical Council Register as of July 2022 showed that 9,956 doctors gained their primary qualification from Nigeria. Only recently in the UK, Essex Partnership University National Health Service Trust is employing 66 nurses from Botswana to start work in August 2022. The largest source countries supplying doctors to the UK are India, Pakistan, Egypt, and Nigeria who constitute about 20% of doctors working in the UK in 2022.,
Causes of HRH migration
There is an absolute shortfall of HRH globally. The shortfall in numbers of HRH as of 2019 was 6.4 million physicians, 30.6 million nurse/midwives, 3.3 million dentistry personnel, and 2.9 million pharmaceutical personnel. The shortage is most pronounced in low- and middle-income countries and in many of the countries, the HRH density falls below the minimum prescribed level of48.6/100.000.
It must be noted that a few countries deliberately produce HRH for export for example the Philippines where nurses are trained to levels beyond what the country needs to enhance their ability to be employed outside the country and bring foreign exchange to the nation. The so-called “push factors” are well known. They include poor career paths, poor financial incentives, socio-economic challenges, and limited opportunities for growth and to increase competencies and skills. HRH who migrated from South Africa in the early part of the 21st Century gave security challenges as important reasons for leaving the country. Such security problems are now important in Nigeria where many physicians have been abducted. The push factors are the opposite. Destination countries offer HRH opportunities for growth, career development, improved skills, and a better ambience for social and economic development., Perhaps one difficult area for many HRH is the lack of understanding by their governments to either understand or be unwilling to deal with the problem. Some authors have identified poor administration and responses across different levels of governance as contributory factors to the health workforce crises in Nigeria. Whereas a former secretary of health of the UK admitted that recruitment of overseas health workers by the UK National Health Service was morally dubious and that the NHS would simply fall over without clinicians from abroad.
Health inequalities are the unjust differences in the health status of individuals, families, population groups, and nations because of the disadvantages they suffer. The causes of health inequalities are global economic forces, macro socio-political environment, political priorities, and decisions that work to produce unequal distribution in income, power, and wealth. Such unequal distribution affects people at the individual level to produce inequalities. The inequalities manifest as worsening health indicators, poor health, and higher morbidity, and mortality rates. The differences occur due to ethnicity, gender, occupation, religion, social status, and social capital.
The migration of HRH by itself is not a case of health inequalities. However, it is known that inequalities are more and worsen where there are fewer HRH and where HRH migrate from which are nations with existing deficiencies. This is shown in [Table 1]. The median HRH density for the Commonwealth regions shows a direct relationship with universal health coverage but an indirect one with mortality indices.
|Table 1: HRH density in the Commonwealth Regions and Selected Health Indices*,|
Click here to view
One effect of the continuing migration is that the people from the source nations are at higher risks of disease, death, and lower life expectancy. Moreover, a report showed a four-fold differential (higher) in under-five mortality rate and a two-fold higher risk of adult mortality between countries where the HRH density is high compared with those with lower health workers. The outcome of the migration is worsening of the health indicators of the nations exporting their health workers. No single factor can account for all the disparity in health status. However, nations that are not able to keep their HRH are the same that do not produce enough, have inadequate facilities, poorer payment systems thus compounding the complex problem of health worker migration facing many countries making achieving the third sustainable development goal (SGD3) challenging. In addition, the source countries lose an unquantifiable quantum of “indigenous human capital” with all its associated costs. The need for urgent solutions to tackling the health worker migrant crisis is now greater than before.
Solutions to tackling the HRH migrant crisis
The solutions to addressing HRH migration in a just, ethical, and equitable manner are well known but ignored and not implemented as this is more convenient for the parties concerned. There are codes developed by the WHO, the Commonwealth Health Ministers, and the United Kingdom,, which all state the principles of equal access to health by all peoples, the rights of HRH to freely move within the provisions of relevant laws, transparency, fairness, and mutual benefits and the right of states to train, educate and sustain HRH to meet the needs of their people. The WHO has a workforce safeguard list of countries, 47 in number as of 2020 where because of severe shortage, recruitment of HRH and migration should be restricted and only occur with government-to-government collaboration. However, in practice, this is not so. Almost four out of five countries on the list are from Africa and about three out of ten are members of the Commonwealth. Nigeria, Ghana, and Pakistan are on the list. The global strategy for HRH by the year 2030 is a further development to tackling the challenges. Some of the milestones set include that each nation should produce enough HRH for its people, reduce dependence on foreign HRH by 50%, and improve completion rates in medical and nursing programmes.
A framework developed by a group of researchers is very useful in solving HRH problems. The framework starts with a pre-university pool of young persons who can be trained to become health workers. Policies need to be developed to attract such talented and brilliant persons to the health sciences. Policies should target next the development and training of HRH, their deployment and retention as well as maldistribution and inefficiencies. The policies need to be inclusive of both the public and private sectors. These if implemented will lead to the production of sufficient HRH, their retention in the countries where they are produced, and reduce HRH migration. The solutions are to be implemented by developing nations, high-income countries, and the international community.
In the LMIC countries, broad policies must be developed and implemented to produce adequate numbers of, sustain and retain HRH. Collaboration with the education sector is a critical first step. The rather restrictive numbers of HRH to be trained should be increased and new training institutions established where feasible. The curriculum should be aligned with field practice. Production of graduates should be in tandem with the current and future needs of the population. Special schemes may be necessary for the health sciences by attracting talented students in secondary schools, offering them scholarships, and counselling to draw them to the health fields. There is the need to expand the training curriculum in LMIC to be up to date, with more emphasis on skills and competencies so that HRH there can be comparable to those produced elsewhere. Coupled with this is the need to provide short training courses for HRH and create schemes of service to accommodate such training for career advancement.
Continuous professional development, acquisition of better skills and knowledge, better career paths, higher levels of compensation and strengthening the health system are further steps needed. Validation of training, accreditation and international recognition of training institutions in LMIC is also a useful strategy such that the HRH do not feel inferior to those trained in the global north and endlessly strive to migrate there, rather to work with dignity and pride in their own countries. Innovation has a strong role to play in tackling HRH migration and addressing workforce shortages. This may be through telemedicine, deeper internet penetration, and the development of applications. These will make it possible for HRH to attend online courses, interact and learn operative techniques, and seek second opinions with guidance from experts in the developed world thus bridging the knowledge and technology gap.
South-south collaboration such as the Technical Aids Corps programme of Nigeria where Nigeria was fully funding and seconding her highly skilled manpower in many fields to other African nations with deficits who requested help. This has increased the pool of such manpower including health workers in the supported nations. Regional collaboration is another perspective where countries in the same regions can work together to produce mutually beneficial training with reciprocity for recognition. This is being done in the West African Health Community where the graduates can work in the West-African sub-region with the qualifications and earn commensurate remuneration.
Governments in LMIC should allocate more resources and a higher proportion of GDP should be allocated to the health system to strengthen health systems. It would also mean more innovative ways of funding the health systems and less reliance on international donors. National health accounts and expenditures on health should be available to track progress in these areas. Government alone cannot fund or sustain health systems. Wealthy citizens of LMIC and willing donors in high-income countries should be encouraged to endow facilities, and equipment, sponsor training and fellowships and pay for highly-skilled staff to come to developing countries. These can be an invaluable source of support to the health systems in LMIC. Governments in LMIC should provide honest and purposeful governance in all sectors. Adequate attention must be paid to the overall socio-economic development of their nations through the provision of basic amenities such as power, water, a good network of roads, and housing which will lift their citizens out of poverty and improve their health. Civil society can play stronger roles through advocacy, lobbying, consensus building, and holding both governments and HRH accountable.
Destination countries have many roles to play especially in supporting health systems in LMIC countries. This may include providing highly skilled experts to support the training of both undergraduate and postgraduate students in the source countries so that the level of training is higher. Another strategy is to provide resources or counterpart funding to improve facilities needed for service delivery. Sponsored and bonded training should be provided in the high-income countries especially in areas where local expertise is lacking in LMIC but there should be institutionalized guarantees of return, appropriate deployment and recognition when such trained HRH return to the source country. The international community especially funding agencies can help in supporting HRH research, establishing a comprehensive observatory on HRH, and strengthening health systems in LMIC. Awareness of the Commonwealth Code and commitment to its implementation by member countries as well as the WHO code of ethics is essential if the HRH migration crises are to be solved. There is no single measure or combination of measures that will eliminate health care worker migration rather the objective is to minimise the problems associated with HRH migration and reduce unethical migration of HRH globally
| Conclusion|| |
HRH migration continues to have undesirable consequences for citizens of the Commonwealth. It must be seen as a crisis and an emergency. Solving it requires a collaboration of all countries, the health workers, the civil society, and the citizens.
We are deeply indebted to the President of the Commonwealth Medical Association, Dr Osahon Enabulele
This paper was first delivered in part as a Keynote address delivered at the Commonwealth Medical Association Session at the Commonwealth Peoples’ Forum, Kigali, Rwanda on Tuesday, June 21, 2022.
Financial support and sponsorship
Conflict of interest
| References|| |
World Health Organization. Basic Documents. 45th ed. Geneva: World Health Organization; 2005. Available from https://apps.who.int/iris/handle/10665/43134
. [Last accessed on 17 Aug 2022].
Winslow CE The untilled fields of public health. Science 1920;51:23-33.
World Health Organization. International Conference on Primary Health Care. Alma-Ata, USSR: World Health Organization; 1978.
United Nations. Sustainable Development Goals. Available from https://sdgs.un.org
. [Last accessed on 09 Jul 2022].
United Nations Trust Fund for Human Security. Human security in theory and practice. Available from https://www.unocha.org
. [Last accessed on 09 Jul 2022].
World Health Organization. Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and Their Measurement Strategies. Geneva: World Health Organization; 2010.
The Commonwealth. Available from https://thecommonwealth.org/
. [Last accessed on 09 Jul 2022].
Clemens MA, Pettersson G New data on african health professionals abroad. Hum Resour Health 2008;6:1.
World Health Organization. WHO Global Code of Practice on the International Recruitment of Health Personnel: Fourth round of national reporting. Available from www. who.int
. [Last accessed on 09 Jul 2022].
Organisation for Economic Cooperation and Development. Health workforce migration. Available from www.stats.oecd.org
[Last accessed 05 Jun 2022].
The Nursing and Midwifery Register. Available from www.nmc.org.uk
[Last accessed on 27 Jul 2022].
General Medical Council. Registered doctors by country of primary medical qualification. Available from https.//www.gmc-org.uk
. [Last accessed on 27 Jul 2022].
Devereux E Essex mental health trust recruits 66 nurses from Botswana. Available from www.nursingtimes.net
[Last accessed on 09 Jul 2022].
NHS hiring more doctors from outside UK and EEA than inside for first time. Available from www.theguardian.com
[Last accessed on 01 Jun 2022].
Leading countries of qualification of doctors based in the United Kingdom (UK) in 2022. Available from www.statista.com
[Last accessed on 02 Jun 2022].
GBD 2019 Human Resources for Health Collaborators. Measuring the availability of human resources for health and its relationship to universal health coverage for 204 countries and territories from 1990 to 2019: A systematic analysis for the Global Burden of Disease Study 2019. Lancet 2022;399:2129-54. https://doi.10.1016/S0140-6736(22)00532-2
World Health Organization Health Workforce Support and Safeguards List, 2020. Available from https://www.who.int
[Last accessed on 13 Jun 2022].
Eastwood JB, Conroy RE, Naicker S, West PA, Tutt RC, Plange-Rhule J Loss of health professionals from Sub-Saharan Africa: The pivotal role of the UK. Lancet 2005;365:1893-900.
Bidwell P, Laxmikanth P, Blacklock C, Hayward G, Willcox M, Peersman W, et al
. Security and skills: The two key issues in health worker migration. Glob Health Action 2014;7:24194.
Nair M, Webster P Health professionals’ migration in emerging market economies: Patterns, causes and possible solutions. J Public Health (Oxf) 2013;35:157-63.
Adeloye D, David RA, Olaogun AA, Auta A, Adesokan A, Gadanya M, et al
. Health workforce and governance: The crisis in Nigeria. Hum Resour Health 2017;15:32.
Public Health Scotland. What are health inequalities? Available from www.healthscotland.com
. [Last accessed on 07 Jun 2022].
Kröger H, Pakpahan E, Hoffmann R What causes health inequality? A systematic review on the relative importance of social causation and health selection. Eur J Public Health 2015;25:951-60.
World Health Organization. World health statistics 2021: Monitoring health for the SDGs, sustainable development goals. Geneva: World Health Organization; 2021.
World Health Organization. The WHO Global Code of Practice on the International Recruitment of Health Personnel. Geneva: WHO; 2010. http://www.who.int/hrh/migration/code/practice/en/
. [Last accessed on 22 Jun 2022].
Commonwealth Code of Practice for the International Recruitment of Health Workers. Available from www. https://www.aspeninstitute.org/
. [Last accessed on 09 Jul 2022].
Code of Practice for the international recruitment of health and social care personnel in England. Available from https://www.gov.uk
. [Last accessed on 12 Jun 2022].
World Health Organization. Global strategy on human resources for health: Workforce 2030. Geneva: World Health Organization; 2016.
Sousa A, Scheffler RM, Nyoni J, Boerma T A comprehensive health labour market framework for universal health coverage. Bull World Health Organ 2013;91:892-4.
Witt J Addressing the migration of health professionals: The role of working conditions and educational placements. BMC Public Health 2009;9 Suppl 1:S7. https://doi.10.1186/1471-2458-9-S1-S7
Committee on Pediatric Workforce, Marcin JP, Rimsza ME, Moskowitz WB The use of telemedicine to address access and physician workforce shortages. Paediatrics 2015;136:202-9. https://doi:10.1542/peds.2015–125
Abebanwi W Government-led service: The example of the Nigerian Technical Aid Corps. Voluntary Action 2005;7:57-68.
West African Health Organisation. Available from https://www.wahooas.org/web-ooas/en
. [Last accessed on 09 Jul 2022].