It is now more than a decade since the acknowledgement of the health human resources crisis that exists in many low-income countries. During that decade much attention has focused on addressing the “pull” factors (e.g. developing voluntary international recruitment guidelines and bilateral agreements between recruiting and source countries) and on scaling up the supply of health professionals. Drawing on research conducted in two sub-Saharan African countries, we argue that a critical element in the human resources crisis is the poor working environments in these countries that not only continue to act as a strong “push” factor, but also impact on the motivation and performance of those who remain in their home countries. Unless attention is focused on improving work environments, the human resources crisis will continue in a vicious cycle leading to further decline in the health systems of low-income countries.
TopIntroduction
Much has been written in the past decade about the health workforce crisis that is crippling health service delivery in many middle and low-income countries (Hagopian, Thompson, Fordyce, Johnson & Hart, 2004; Ntuli, 2004; McAuliffe & MacLachlan, 2005; Padarath et al., 2003). High-income countries with high salaries and attractive living conditions are drawing qualified doctors and nurses from these countries to fill gaps in their own health human resources pool. The emigration of skilled labour in search of better returns on knowledge, skills, qualifications and competencies is depleting human capital in many developing countries (Lowell & Findlay, 2001). The UN Commission for Trade and Development estimated that each migrating African professional represents a loss of US $184,000 to Africa (Oyowe, 1996). While low income countries have limited resources for training healthcare professionals, the migration of those who are trained to conventional international standards has made dependence on such cadres increasingly precarious (McAuliffe & MacLachlan, 2005). It is widely acknowledged that Africa’s health workforce is insufficient and will be a major constraint in attaining the Millennium Development Goals (MDGs) for reducing poverty and disease (JLI, 2004). The Joint Learning Initiative (JLI) report (2004) indicated that the low health worker density in some countries has already had a major impact on maternal and child mortality. African countries, especially sub-Saharan Africa, have a very low density health workforce, compounded by poor skill mix and inadequate investment in training and development (Chen et al., 2004).
Beyond the national level shortages, imbalances in geographic distributions, especially between rural and urban areas, exacerbate the health human resources crisis (Dussault & Franceschini, 2006). In the countries that do have enough doctors, geographical mal-distribution is so severe that there may be ratios of 1 physician to500 patients in the city, while remote districts suffer from a 1:100,000 physician to patient ratio. The migration of health professionals from one geographical region to another, from the public to the private sector, from areas of generalization to areas of specialization, from medical to non-medical fields, and from one country to another affects the capacity of the health system to maintain adequate coverage, access and utilization of services (Awases, Gbary, Nyoni & Chatora, 2004; Padarath et al., 2003).
Health workers’ migration is influenced by a combination of factors that either “push” professionals from the source countries or “pull” them to a recipient country. Push and pull factors refer to influences that are felt by professionals within the source country that either create an impetus to leave or an attraction to seek work in a recipient country. A WHO study (1996) suggested that regardless of the pull factors from recipient countries, migration only seems to occur if there are strong push factors from the source country. This chapter draws on research in two sub-Saharan African countries conducted over the past four years and argues that unless attention is focused on addressing the push factors, the human resources crisis will continue in a vicious cycle leading to further decline in the health systems and health service delivery in low-income countries.