Why is there a global medical recruitment and retention crisis?

Even before the COVID-19 pandemic, countries at all stages of development experienced healthcare worker shortages. This medical recruitment and retention crisis prompted the creation of the World Health Organization’s (WHO) Global Strategy on Human Resources for Health: Workforce 2030 in 2016, which led to a 29% growth in the health workforce to 65 million by 2020.

It seemed like steps were being taken in the right direction to address healthcare worker shortages. But then the COVID-19 pandemic struck. COVID-19 stretched healthcare workers to the limit. Existing challenges around burnout, mental health, well-being and workplace violence were exacerbated on top of the persistent high risk of exposure to infection and death.

Even before the pandemic, the healthcare sector was one of the most hazardous sectors to work in. Healthcare workers are four times more likely than other professionals to be assaulted, with those most at risk including junior doctors and nurses and those working in government hospitals, emergency departments and intensive-care units.

India has a disproportionately high share of violence-related incidents and garnered global attention for the particularly discriminatory and vehement opposition to doctors during the COVID-19 pandemic. A study found that 75% of Indian doctors have experienced violence of some kind in the workplace. Despite measures aimed at reducing this, such as more stringent laws, fines as high as Rs 1,000,000 for violence against healthcare workers and enhanced security, the problem seems to be worsening.

The consequences of violence against healthcare workers can be serious: deaths or life-threatening injuries, reduced work interest, job dissatisfaction and impaired functioning, more leave days, depression, post-traumatic stress disorder, the decline of ethical values, increased practice of defensive medicine, lower patient safety and more adverse events. But there are also consequences for healthcare systems and broader society as violence catalyses the potential for burnout, which leads to many professionals leaving and reduced recruitment into the sector.

“While there are several laws protecting our safety and well-being as physicians in India, the threats of violence and burnout are real and are often why doctors are considering other professions or are looking to pursue medical specialities in other countries,” explains
Kashish Malhotra, a physician in the Department of Internal Medicine, Dayanand Medical College and Hospital.

There will be an estimated shortfall of 10 million healthcare workers worldwide by 2030, primarily in low- and middle-income countries. This inequitable distribution is aggravated as physicians are increasingly migrating to higher-income countries in search of improved working conditions and better career opportunities. This medical recruitment and retention crisis has economic and health consequences in the low- and middle-income countries of origin, as well as implications for the broader global health community as disparities in healthcare workers' skill sets and availability widen. For example, incorrect use of antibiotics due to limited specialisms or experience in low- and middle-income countries further exacerbates global antimicrobial resistance problems.

And, as healthcare workers arrive in high-income countries they continue to face problems: antisocial hours, shift patterns that are antithetical to family life and high levels of stress, for example. Many healthcare workers suffer from a lack of job satisfaction and ‘moral injury’ as frustration builds at being constrained and unable to care for patients holistically. Added to this are slow and bureaucratic systems and workflows, increasing boredom due to dwindling autonomy and a limited sense of community through working daily in unfamiliar environments with unfamiliar colleagues and having no dedicated workspace.

Not to mention the limited pay and disincentives, such as the NHS pension scheme tax rules in the UK, which are forcing some of the most experienced doctors to retire, reduce their workload and abandon leadership positions for fear of incurring significant charges, in addition to pay-as-you-earn and other tax charges. It is no surprise the healthcare workforce is at a breaking point.

Henry De Berker, Plastic Surgery Registrar at Health Education North West England NHS, says: “Working antisocial hours and enduring stress is ultimately worth it when you feel you have made a difference [in] someone’s life and done a good job. But underfunding, physician shortages and growing demands conflict with our ability to do all the activities that comprise ‘caring’ beyond the bare minimum, which is distressing.”

A new Commonwealth Fund survey finds that a majority of primary care doctors across ten higher-income countries say they are burned out and stressed and many feel the pandemic has negatively impacted the quality of care they provide. Younger physicians (under 55) were more likely to experience stress, emotional distress or burnout. Half or more of older physicians in most countries reported they would stop seeing patients within the next three years, leaving a primary care workforce made up of younger, more stressed and burned-out physicians.

Resilient healthcare systems are defined as one of the strategic pillars in the Health and Healthcare Strategic Outlook and having a motivated, highly skilled and resourced healthcare workforce is central to this.

The Strategic Outlook explores eight levers public and private stakeholders can deploy to address issues in health and healthcare, some of which can help address concerns around healthcare worker shortages. For example, in India better policies that protect healthcare workers from violence should be developed, using recent WHO guidance as a reference point. Public-private partnerships and cross-industry collaboration can be better utilised to incentivise young aspiring doctors to view medicine as a viable, long-term career path and, for those that do make the choice, reward them adequately to stay, not only in the profession but also in the country.

Across all countries, digitalisation and decentralisation levers can be used jointly to advance alternative care models (e.g. telecare and homecare), which will help alleviate pressure on acute care settings and free up healthcare workers' time to enhance their care delivery, increase satisfaction and improve outcomes.

There is no one-size-fits-all solution and although the effects may not be felt overnight, urgent and extreme action is needed now to address this global medical recruitment and retention crisis.