International medical migration: A critical conceptual review of the global movements of doctors and nurses

Only a few studies have investigated the link between human resources for health and health outcomes, and they arrive at different conclusions. We tested the strength and significance of density of human resources for health with improved methods and a new WHO dataset. We did cross-country multiple regression analyses with maternal mortality rate, infant mortality rate, and under-five mortality rate as dependent variables. Aggregate density of human resources for health was an independent variable in one set of regressions; doctor and nurse densities separately were used in another set. We controlled for the effects of income, female adult literacy, and absolute income poverty. Density of human resources for health is significant in accounting for maternal mortality rate, infant mortality rate, and under-five mortality rate (with elasticities ranging from -0.474 to -0.212, all p values < or = 0.0036). The elasticities of the three mortality rates with respect to doctor density ranged from -0.386 to -0.174 (all p values < or = 0.0029). Nurse density was not associated except in the maternal mortality rate regression without income poverty (p=0.0443). In addition to other determinants, the density of human resources for health is important in accounting for the variation in rates of maternal mortality, infant mortality, and under-five mortality across countries. The effect of this density in reducing maternal mortality is greater than in reducing child mortality, possibly because qualified medical personnel can better address the illnesses that put mothers at risk. Investment in human resources for health must be considered as part of a strategy to achieve the Millennium Development Goals of improving maternal health and reducing child mortality.

Ever since the 2006 World Health Report advocated increased community participation and the systematic delegation of tasks to less-specialized cadres, there has been a great deal of debate about the expediency, efficacy and modalities of task shifting. The delegation of tasks from one cadre to another, previously often called substitution, is not a new concept. It has been used in many countries and for many decades, either as a response to emergency needs or as a method to provide adequate care at primary and secondary levels, especially in understaffed rural facilities, to enhance quality and reduce costs. However, rapidly increasing care needs generated by the HIV/AIDS epidemic and accelerating human resource crises in many African countries have given the concept and practice of task shifting new prominence and urgency. Furthermore, the question arises as to whether task shifting and increased community participation can be more than a short-term solution to address the HIV/AIDS crisis and can contribute to a revival of the primary health care approach as an answer to health systems crises. In this commentary we argue that, while task shifting holds great promise, any long-term success of task shifting hinges on serious political and financial commitments. We reason that it requires a comprehensive and integrated reconfiguration of health teams, changed scopes of practice and regulatory frameworks and enhanced training infrastructure, as well as availability of reliable medium- to long-term funding, with time frames of 20 to 30 years instead of three to five years. The concept and practice of community participation needs to be revisited. Most importantly, task shifting strategies require leadership from national governments to ensure an enabling regulatory framework; drive the implementation of relevant policies; guide and support training institutions and ensure adequate resources; and harness the support of the multiple stakeholders. With such leadership and a willingness to learn from those with relevant experience (for example, Brazil, Ethiopia, Malawi, Mozambique and Zambia), task shifting can indeed make a vital contribution to building sustainable, cost-effective and equitable health care systems. Without it, task shifting runs the risk of being yet another unsuccessful health sector reform initiative.

This paper provides a context for this special edition. It highlights the scale of the challenge of nursing shortages, but also makes the point that there is a policy agenda that provides workable solutions. An overview of nurse:population ratios in different countries and regions of the world, highlighting considerable variations, with Africa and South East Asia having the lowest average ratios. The paper argues that the 'shortage' of nurses is not necessarily a shortage of individuals with nursing qualifications, it is a shortage of nurses willing to work in the present conditions. The causes of shortages are multi-faceted, and there is no single global measure of their extent and nature, there is growing evidence of the impact of relatively low staffing levels on health care delivery and outcomes. The main causes of nursing shortages are highlighted: inadequate workforce planning and allocation mechanisms, resource constrained undersupply of new staff, poor recruitment, retention and 'return' policies, and ineffective use of available nursing resources through inappropriate skill mix and utilisation, poor incentive structures and inadequate career support. What now faces policy makers in Japan, Europe and other developed countries is a policy agenda with a core of common themes. First, themes related to addressing supply side issues: getting, keeping and keeping in touch with relatively scarce nurses. Second, themes related to dealing with demand side challenges. The paper concludes that the main challenge for policy makers is to develop a co-ordinated package of policies that provide a long term and sustainable solution. This paper highlights the impact that nursing shortages has on clinical practice and in health service delivery. It outlines scope for addressing shortage problems and therefore for providing a more positive staffing environment in which clinical practice can be delivered.