The U.S. is facing unprecedented health care labor shortages and related cost pressures. In the U.K., the National Health Service has witnessed its largest nursing strike in history alongside junior doctor strikes, which have been prompted by staffing shortfalls and inadequate pay. Europe is endangered by an aging workforce, growing absenteeism, and health care workers simply quitting the field.
To fill those gaps, international recruitment is on the rise in the Global North. Filipino nurses already make up almost 5 percent of the U.S. nursing workforce. Fifteen percent of health care workers globally are working outside their country of birth. More than one-quarter of physicians in the U.S. and over one-third of doctors in the U.K. were trained elsewhere. Some high-income countries are even cutting out the middlemen. Henry Ford Health, a large nonprofit system based in Michigan, for example, has directly recruited hundreds of nurses from the Philippines. In August 2022, it was reported the NHS was planning to send managers to India and the Philippines to recruit thousands of nurses there.
The benefits for those doing the hiring are obvious: fewer staffing shortages, improved nurse-patient ratios, improved patient outcomes, and lower labor costs (which comprise over half of most hospitals’ budgets). The individual health workers can benefit, too. Emigration often offers opportunities for higher income, better working conditions, and more or better educational opportunities. This is transformative for families and subsequent generations.
However, international recruitment has painful repercussions for middle- and lower-income countries left behind. A report released in March by the International Council of Nurses found some countries with a tradition of training nurses “for export” are actually facing a huge shortage themselves. The Philippines now acknowledges a shortfall of 350,000 nurses domestically. The labor pull to higher-income countries leaves lower-income countries less able to meet the burden of disease and undermines economic and social stability. It also leaves these countries shouldering the debt of training costs, which is never recouped in service. There are no simple or fast solutions to this problem. Instead, they will require both global and domestic policy.
In an effort to harmonize global movements of health workers, the World Health Organization created the Global Code of Practice on the International Recruitment of Health Personnel, which respects individual workers’ rights to migrate and acknowledges source countries’ lost investment. However, there is no legal backing, which means that it offers no accountability mechanism beyond public pressure.
The next step is a stronger commitment from the Global North, multilaterals, and large funders to train the health workforce in lower- and middle-income countries. There are already global and regional efforts, including the WHO Roadmap for Building the Public Health and Emergency Workforce, an Africa Centre for Disease Control-led effort for the African continent, and various country-led efforts that need support. But we need to see a more concerted, funded effort to address these shortages.
Domestically, high-income countries need to commit to training and hiring more of their own workers, including allocating the necessary budget and timelines to prioritize the pipeline of health workers, train and employ them, and address retention issues by ensuring appropriate pay. The U.K. recently announced it will double the number of doctors and nurses it trains to meet staffing shortages. The U.S. would do well to follow suit; the Association of American Medical Colleges estimated in 2021 that the country could be short 124,000 doctors alone by 2034, but Congress has so far failed to act.
In a promising step, in 2021, Kenya and the U.K. agreed to facilitate the recruitment of Kenyan health workers to the U.K. with acknowledgement of the code and international practice. While the specifics on funding or material capacity-building efforts to mitigate worsening shortages in Kenya are not explicitly mentioned, the governments are transparently documenting their bilateral agreement, and it seems only a small number of unemployed nurses have been sent to the U.K. thus far.
The U.K.-Kenya example is one small drop in an ocean of need. The health worker shortage is a global challenge that we keep pushing down the line. We cannot solve it by shifting workers around the globe.
Vanessa Kerry is CEO of Seed Global Health and director of the Program in Global Public Policy and Social Change in the Department of Global Health and Social Medicine at Harvard Medical School. She is also a physician at Massachusetts General Hospital. Travis Bias is a family medicine physician and chief medical officer of clinician solutions at 3M. He previously taught medicine in Uganda and Kenya.
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