There is a shortage of health professionals mainly in some parts of the countryside of Brazil. Areas with poor living conditions and restricted supply of goods, limited infrastructure or access to education tend to be less attractive to health professionals (including doctors) to live and work. This leads to a lack of health professionals willing to deliver healthcare to this population. In addition, on average, the number of trained health professionals is below the necessary to meet population’s demand. Brazil suffers with lower numbers and bad distribution of trained health professionals.

In Hong Kong, there is general shortage of healthcare manpower in the health system (Food and Health Bureau, 2017b). According to the Association of Hong Kong Nursing Staff, the nurse-to-patient ratio of night-shifts in public hospitals in 2013 was 1:24. This means that each nurse needed to take care of 24 patients on average, and such ratio was far worse than the international standard at 1:6 (HKSAR Government, 2018, April 25). In 2016-2017, there was a shortage of 300 doctors and 600 nurses. By projection to 2030, there will be a shortage of over 1,000 doctors and 1,600 nurses (HKSAR Government, 2017, July 12). The actual workforce requirements of health services are projected from 138,000 in 2017 to 183,800 in 2027. The projected average annual rate of change is +2.9% (Census and Statistics Department, 2019d).

The Hospital Authority has been implementing various measures to retain staff and alleviate the tight workforce situation of frontline nursing staff, including continuous recruitment of nurses, ward clerks and assistants, establishment of the Special Retired and Rehire Scheme, enhancement of promotion and training opportunities, improvement of work environment, enhancement of preceptorship support, and reinstating the annual increment mechanism (HKSAR Government, 2018, April 25). To address workforce shortages in the short-term, the Hospital Authority has employed non-locally trained doctors with limited registration to practise in Hong Kong (HKSAR Government, 2017, July 12). Besides, the Government has substantially increased the number of funded healthcare training places by about 60% (about 1,800 students) over the past 10 years. It also encouraged self-financing institutions to provide more subsidised training places (about 860 students) for healthcare professionals in the 2018/19 academic year (HKSAR Government, 2018, April 25).

References:

Census and Statistics Department. (2019d). Report on Manpower Projection to 2027. Retrieved from https://www.statistics.gov.hk/pub/B1050016E2019XXXXE0100.pdf

Food and Health Bureau. (2017b). Report of the Strategic Review on Healthcare Manpower Planning and Professional Development.

HKSAR Government. (2017, July 12). LCQ17: Manpower of healthcare professionals [Press release]. Retrieved from https://www.info.gov.hk/gia/general/201707/12/P2017071200517.htm?fontSize=1

HKSAR Government. (2018, April 25). LCQ19: Healthcare manpower [Press release]. Retrieved from https://www.info.gov.hk/gia/general/201804/25/P2018042500725.htm?fontSize=1

The attrition rate in the health sector in India is assumed to be around 25%; however, the rates are higher for Auxiliary Nurse Midwife (ANMs) and nurses (about 40%) (KPMG, 2017). Even as the public health system in India faces considerable challenges due to staffing shortage, the patterns of health staff vacancies in India has changed significantly over the past few years. Especially, the ratio for doctors and nursing personnel has also shown upward trends. The doctor-to-nurse ratio is also likely to improve with more nurses joining the workforce. The network of Accredited Social Health Activists (ASHAs) (ASHAs are community health workers appointed under the National Rural Health Mission, who act as a point of contact between the public health services and the community) has expanded to cover all rural parts of the country. Simultaneously, the size of Anganwadi Workers and ANMs has also increased (Anganwadi is a government-sponsored child-care and mother-care development programmes in India at the village level). The number of available pharmacists, support staff, and specialised cadres (e.g., psychologists for child development screening, audiologists and optometrists), however, remains low. There is an effort to increase the number of public health/epidemiology personnel, anaesthetists and sonologists in the system.

There are areas within the country where the public health system is almost the sole provider of health services (e.g., Himachal Pradesh) while in certain areas, care is mostly delivered through informal private providers (e.g., rural Haryana and Bihar). It is expected that the healthcare sector would require about a 100% growth in terms of workforce by 2022 in comparison to 2013, so that it can meet the market demand (KPMG, 2017) .The demand will be especially high for nurses and midwifery cadre. In particular, as the demand for quality tertiary and quaternary care services continues to increase, there is a substantial need for specialised human resources such as nurses, doctors, and allied health professionals (KPMG, 2017). However, outreach services in urban areas are affected with issues of unavailability, as well as poor optimisation of staff. Challenges in terms of selection, deployment, employability, and remuneration have been highlighted. The majority of the health care staff across the country is contractual, especially, the allied personnel (allied health professionals are associates/technicians/technologists who support a number of services such as diagnosis, treatment, prevention, rehabilitation etc. (Government of India, 2018b). Contractual agreements and performance linked payments with lack of clarity on career track progression are understood to contribute to worker attrition and migration. Challenges in selection, deployment, employability, and remuneration have also been highlighted (Rajbangshi et al., 2017).

References:

Government of India. (2018b). THE ALLIED AND HEALTHCARE PROFESSIONS BILL, 2018. Available from http://164.100.47.5/committee_web/BillFile/Bill/14/113/LX%20of%202018_2019_2_14.pdf

KPMG (2017). Human resources and skill requirements in the health sector. Ministry of Skill Development and Entrepreneurship and National Skill Development Corporation. Available from: https://skillsip.nsdcindia.org/sites/default/files/kps-document/Healthcare.pdf

Rajbangshi, P. R., Nambiar, D., Choudhury, N., & Rao, K. D. (2017). Rural recruitment and retention of health workers across cadres and types of contract in north-east India: A qualitative study. WHO South-East Asia Journal of Public Health, 6(2), 51–59. Available from: https://doi.org/10.4103/2224-3151.213792

One of the issues in the provision of health care faced by Indonesia concerns the disparities between the number of health care workers available in urban and rural areas. For example, in 2006, there were 36.18 physicians per 100,000 residents available in urban parts of Indonesia, while there were only 5.96 in rural areas. These disparities were greatest in provinces outside Java and Bali (Rokx et al., 2010, p.43).

Since the 1970s, physicians and midwives are allowed to operate in dual practice. This means that while working in the public system, they can get additional income from working in private practices outside public working hours. It was hoped that this would improve health worker retention, particularly in rural and remote areas as well as to increase the supply for service by incentivising the provision of longer work hours. In 2007, almost 70 per cent of puskesmas physicians and approximately 90 per cent of midwives were reported to have taken up additional private practice (Rokx et al., 2010, p.42).

The dual practice policy, however, may have not been entirely successful as it has been reported that the number of new graduates seeking employment in rural and remote areas has decreased, perhaps because there are fewer opportunities for private practice. Instead, shortening the mandatory service period as part of one of the governments contracting programmes (PTT) from three years to six months increased the number of health workers willing to take up remote postings (Rokx et al., 2010, pp.17,42).

A second issue faced by the Indonesian health system concerns the high turnover rates. According to a study investigating patterns of nurse turnover rates in a private hospital in East Java, turnover rates were higher than acceptable (between 12-34%) (Dewanto & Wardhani, 2018, p.1). Factors associated with the risk of turnover include being aged up to 30 years, unmarried, and working for more than 3 years in the hospital. Personal drivers were most commonly cited as motivating the nurses’ resignation (e.g., moving locations to follow their spouses or families, getting married, having children, following a pregnancy program, and continuing their education). Other drivers to turnover are accepting job offers from other organizations and dissatisfaction with the original hospitals’ working conditions. Nurse turnover rates have consequences for patients, doctors, the other nurses, and the hospitals.

This results in a gap between the manpower available to respond to current and projected needs for different professions within public hospitals. The ‘Development Plan for Healthcare Manpower 2011-2025’ also offers estimates around the cost of human resources planning in healthcare at national level. Estimates include cost for training and education for each profession.

References:

Dewanto, A., & Wardhani, V. (2018). Nurse turnover and perceived causes and consequences: A preliminary study at private hospitals in Indonesia. BMC Nursing, 17(Suppl 2), 1–7. https://doi.org/10.1186/s12912-018-0317-8

Kementerian Kesehatan Republik Indonesia. (2011). Rencana Pengembangan Tenaga Kesehatan Tahun 2011 – 2025. September.

Rokx, C., Giles, J., Satriawan, E., Marzoeki, P., Harimurti, P., & Yavuz, E. (2010). New Insights Into the Provision of Health Services in Indonesia: A Health Workforce Study. https://books.google.com/books?id=7l7NnxfGfycC&pgis=1

The Caribbean Commission on Health and Development Report (CARICOM, 2005; as cited in IOM, 2018) reported that there were 2,256 registered nurses in the health sector as well as a vacancy rate of 58.3 per cent. The impact of emigration on the job vacancies gaps recorded was mainly of doctors and nurses, but the gaps in the health system due to emigration also included pharmacists, radiologists, and medical laboratory technologists (IOM, 2018).

In 2016, the Jamaica Ministry of Health detailed the nature of the health sector human resource gap. In some specialised areas of nursing, for example among public health nurses, there is as much as a 74 per cent gap between staffing needs and the number of available staff. There was a 70.7 per cent shortfall of nurse anaesthetists and a 68.1 per cent shortfall for psychiatrists. For many other specialisations, there are significant shortfalls in staffing with an estimated 54 per cent overall shortage (MOH, 2016 as cited in IOM, 2018).

A local psychiatrist who serves as a stakeholder for the STRiDE Jamaica team also explained that there are no neurologists in primary care in Jamaica. These specialists are available at public hospitals (University Hospital of the West Indies and Kingston Public Hospital), which line up with the earlier description of the relationship between primary and secondary care services in Jamaica. He also advises that a newly trained Neuropsychiatrist has joined the Kingston Public Hospital neurology service, but his service is limited, and does not extend to primary care or outpatient care.

References:

Caribbean Community (CARICOM). (2005). Report of the Regional Commission on Health and Development, Caribbean Commission on Health and Development, cited in IOM. (2018). Migration in Jamaica – A Country Profile 2018. Available from: https://publications.iom.int/books/migration-jamaica-country-profile-2018#:~:text=

IOM. (2018). Migration in Jamaica – A Country Profile 2018. Available from: https://publications.iom.int/books/migration-jamaica-country-profile-2018#:~:text=

Vacancies in the health system vary according to cadre, and are mainly noticeable in the public health sector (Chankova, Muchiri, & Kombe, 2009). A report in 2010 indicated that the Ministry of Health had the highest vacancy rate for clinical officers at 35.5%, followed by medical officers at 34.2% then nursing officers at 23.2% with 6.8% unfilled positions for Medical laboratory technologists and technicians (Kiambati, Kiio, & Toweett, 2013). This is relatively high and poses a threat to the efficient delivery of health services (Ministry of Medical Services, 2009). These high vacancy rates have been worsened by  poor infrastructure, insecurity and harsh climatic conditions (MoH, 2013).

Extremely remote rural regions struggle the most with retention and recruitment of personnel. A study conducted in Northern Kenya counties representing 6% of Kenya’s population showed that the counties had access to only 3% of all health workers, while 9% of all health workers were located in Kenya’s capital, Nairobi (representing 8% of the population)  (Ministry of Health, 2015b).  Therefore, careful consideration in terms of better pay and/or hardship allowances needs to be given for health workers deployed in resource-constrained areas in order to increase retention since with better pay, health care workers state that they can work in the harshest areas (MoH, 2013).

Staff turnover rates have been relatively high with more than 50% of physicians and 81% of enrolled community nurses leaving the health workforce between 2005 and 2009. Furthermore, a turnover of 49% was reported among laboratory technologists and technicians during the same period (Kiambati et al., 2013). Some of the common factors resulting in staff turn-over rates in the public health system include retirement, voluntary resignation, death, better pay in private health sector or abroad  (Chankova et al., 2009).

Other factors that have contributed to compromised availability of the health care workers and play a role in turnover rate include lack of employment (not absorbed by the ministry) of trained workers, limited career development opportunities, huge workloads, high prevalence of HIV/AIDS, increased risk of occupational exposure, political violence and social instability (Gross et al.,  2011).

References:

Chankova, S., Muchiri, S., & Kombe, G. (2009). Health workforce attrition in the public sector in Kenya: a look at the reasons. Human Resources for Health, 7(1). http://doi.org/10.1186/1478-4491-7-58

Gross, J. M., Rogers, M. F., Teplinskiy, I., Oywer, E., Wambua, D., Kamenju, A., … Waudo, A. (2011). The impact of out-migration on the nursing workforce in Kenya. Health Services Research, 46(4), 1300–1318. https://doi.org/10.1111/j.1475-6773.2011.01251.x

Kiambati, H., Kiio, C., & Toweett, J. (2013). Understanding the labour of human resources for health in kenya. Working Paper, (November), 29. https://www.who.int/hrh/tools/Kenya_final.pdf?ua=1

Ministry of Health. (2015b). Kenya Health Workforce Report. https://taskforce.org/wp-content/uploads/2019/09/KHWF_2017Report_Fullreport_042317-MR-comments.pdf

Ministry of Medical Services. (2009). National Human Resources for Health: Strategic Plan 2009-2012. Nairobi, Kenya. http://guidelines.health.go.ke:8000/media/hrh-strategic-plan-revised.pdf

MoH. (2013). Human Resources for Health ( HRH ) Assessment report for Northern Kenya: Overview of Health Workforce Distribution across 10 Counties May 2013. https://www.health.go.ke/wp-content/uploads/2015/09/Final%20merged%20NK%20HRH%20Report.pdf

Besides the lack of workforce, the geographical distribution of physicians in Mexico is unequal, as rural localities have a significantly lower density of health professionals overall. While physician density in Mexico City and other large metropolitan areas is elevated, other, less densely populated localities have deficits in health workers and consequently, enormous variations in health care use and health indicators. In addition, more specialised units such as secondary and tertiary hospitals tend to concentrate higher density of health professionals compared to primary care units (Lucio-García et al., 2017, Nigenda et al., 2016).

References:

Lucio-García, C. A., Recaman, A. L., Arredondo, A., Lucio-García, C. A., Recaman, A. L., & Arredondo, A. (2018). Evidencias sobre la inequidad en la distribución de recursos humanos en salud. Horizonte Sanitario, 17(1), 77–82. https://doi.org/10.19136/hs.a17n1.1984

Nigenda, G., Alcalde-Rabanal, J., González-Robledo, L. M., Serván-Mori, E., García-Saiso, S., & Lozano, R. (2016). Eficiencia de los recursos humanos en salud: Una aproximación a su análisis en México. Salud Publica de Mexico, 58(5), 533–542. https://doi.org/10.21149/spm.v58i5.8243

Geographical maldistribution of the medical workforce is a major challenge, particularly for primary care and rural and provincial hospitals, which can struggle to recruit and retain the medical specialists they need (Medical Council of New Zealand, 2018). The distribution of the workforce between specialties is also challenging, with general practice, cardiothoracic surgery, clinical genetics, dermatology, palliative care, orthopaedic surgery, and psychiatry facing shortages (Health Workforce New Zealand, 2016).

The 2015 Health of the Health Workforce report released by Health Workforce NZ in 2016 outlines similar concerns to those of the medical workforce for the nursing, midwifery, allied health professions, and kaiāwhina (non-regulated health workers) (Health Workforce New Zealand, 2016).

References:

Health Workforce New Zealand. (2016). Health of the Health Workforce 2015: A Report by Health Workforce New Zealand. Wellington Ministry of Health. Available from: https://www.health.govt.nz/system/files/documents/publications/health-of-health-workforce-2015-feb16_0.pdf.

Medical Council of New Zealand. (2018). The New Zealand Medical Workforce in 2018. Wellington Medical Council of New Zealand. Available from: https://www.mcnz.org.nz/assets/Publications/Workforce-Survey/434ee633ba/Workforce-Survey-Report-2018.pdf

High staff turnover rates, especially in the public sector, have been a major challenge, for which rates as high as 80% have been reported in some provinces (Rawat, 2012). Attrition rates of health care professionals that do not enter the workforce are estimated at 25% per annum and include both new graduates that struggle to find posts (lack of absorption) and those who migrate to countries with more favourable working environments (DOH, 2011). An added 6% attrition rate is expected due to retirement, change in profession and death (DOH, 2011). Factors fuelling workforce attrition include lack of available posts in the public sector, poor working conditions and lack of personal safety and security, low morale in overburdened health system, and increased risk of contracting TB (DOH, 2011; Rawat, 2012). Factors attracting South African health workforce to countries abroad includes higher remuneration, better resources and working environments, career opportunities, post-basic education, political stability, travel opportunities, and aid work (DOH, 2011).

References:

DOH. (2011). HUMAN RESOURCES FOR HEALTH SOUTH AFRICA (HRH) Department of Health. Available from: http://www.hst.org.za/publications/NonHST Publications/hrh_strategy-2.pdf

Rawat, A. (2012). Gaps and shortages in South Africa’s health workforce. Backgrounder, 31(June), 1–8. https://doi.org/10.13140/RG.2.1.4424.0805