When poverty makes you ill

Health is an expensive commodity for many people. Approximately 1.2 billion people in our world live in extreme poverty. They live in slums and have less than a dollar a day at their disposal. Poverty leads to poor health because it causes people to live in conditions that make them ill. These include lack of permanent residence or restricted living conditions, unclean water, inadequate sanitation, malnutrition and poor or non-existent health care. Even the lack of simple things such as mosquito nets has a strong impact on health in certain regions. More than 100 million people worldwide fall into poverty every year because they have to pay for their health care.

The discrepancy between personnel requirements and available personnel is widening for various reasons. On the one hand, the population’s expectations of the scope and quality of medical services are growing not only in the industrialized countries, but – to an even greater extent – also in the developing countries. On the other hand, the increasing demand is in contrast to a lack of investment in training and equipment for jobs (2). The situation in HIV/AIDS high-prevalence countries has become particularly acute, with a sharp increase in personnel requirements in conjunction with pronounced morbidity and mortality also among health workers (3). In addition, the trend towards a “brain drain” continues unabated, with health workers moving from rural to urban areas, from public to private employers and from poorer to richer countries (4).

On the other hand, this bleak balance is contrasted by noble declarations of intent, such as the Millennium Development Goals (MDGs), which contain three health-related goals: firstly, the reduction of maternal mortality; secondly, the reduction of child mortality; and thirdly, the successful control of the most important health threats such as malaria, tuberculosis and AIDS (5). J. W. Lee, Director-General of the World Health Organization (WHO), who died in 2006, expressed the hope that everyone in the world should have access to a competent, motivated and dedicated health professional regardless of their place of residence (6). However, these intentions and goals rub against the harsh reality. It is foreseeable that, despite some progress, the targets set for health-related MDGs will no longer be achievable for many developing countries (5, 7). This is mainly due to the weak health systems and the blatant shortage of personnel in these countries.

The Joint Learning Initiative Report 2004, prepared by 100 international health experts (2), describes the staff situation in low-wage countries as a crisis characterized by the following factors: dramatic shortage of personnel, imbalance in the distribution of personnel between urban and rural areas, migration of health personnel to rich countries, low wages and the loss of motivation of lagging personnel resulting from all these factors. The report states: “The lack of staff has replaced the financial problems as the most serious obstacle to the implementation of national treatment plans to date. According to WHO, there are 59 million health professionals worldwide, two-thirds of whom are direct health care providers and one-third are health management professionals (1). At present, the WHO expects a shortfall of 4.3 million skilled workers, although this is concentrated in the poorest countries. In addition to the absolute figures, other factors such as the quality of services and the low performance of existing staff are important.

In order to ensure adequate health care, an average of about four health professionals per 1 000 inhabitants is assumed. In fact, however, there are major differences between rich and poor countries: While countries such as Great Britain and the USA have peaks of ten and eleven skilled workers per 1,000 inhabitants respectively, this figure is 1/1,000 (1) in sub-Saharan Africa. Although, for the first time since 2009, more people worldwide live in cities than in rural areas, many of the countries affected by the shortage of skilled workers have significantly more people living in rural regions. 77 percent of doctors and 62 percent of nurses in poor countries work in cities – a clear imbalance at the expense of the rural population (1).

Paying health workers in low-wage countries is totally inadequate, if at all. “Unpaid wages are a major problem in many countries from Eastern Europe to countries in Africa,” notes the World Health Report 2006 (1). Wages vary widely worldwide. Although purchasing power comparisons are always difficult, it should be noted that in countries of Eastern Europe or the former USSR, as well as in many African countries, nurses are often modest at 30 to 50 euros per month and doctors at 100 to 200 euros per month. Despite these low salaries, up to 80 percent of health sector expenditure goes into salary payments, which sheds significant light on the funding gaps in all other health expenditure. Low wages or even the absence of any salary payment also prepare the ground for abuse such as corruption or the much-lamented “under-the-table payments” that often plunge patients into a financial catastrophe (9). It is easy to understand that you cannot feed your family on such minimum wages and are not able to afford even modest luxury. This is also underlined by the results of a study carried out in six African countries, according to which low wages are one of the main causes for the brain drain (10).

There is no doubt that the emigration of health workers is particularly problematic for low-wage countries, which in any case have an extremely thin workforce (4). The Organisation for Economic Cooperation and Development (OECD) is now making targeted efforts to improve the collection of migration statistics (8, 11). The results to date show that no OECD country trains enough staff to meet its own needs. They are therefore relying heavily on additional foreign workers. In 2000, eleven percent of doctors working in Germany and ten percent of nurses were trained abroad. The proportion is even higher in Great Britain:

34 percent of doctors and 15 percent of nurses were foreign professionals in 2002 (11). Recent surveys of medical students in their practical year indicate that an even greater need for foreign doctors is also arising in Germany as a result of the increased emigration of local doctors (12). In this way, poor countries are subsidising the health care systems of rich countries.

Some countries – the Philippines is the best known example of this – even train health personnel for export, although there is a shortage of personnel in their own country (3, 11). Even if one has to respect the individual decision of every skilled worker for better working conditions, a better professional perspective or even just better pay, this brain drain has such negative consequences for the affected population in some countries with a great lack of skilled workers that in 2008 an article with the provocative title “Should active recruitment of health workers from sub-Saharan Africa be viewed as a crime?” appeared in “Lancet”. (13).

It is striking that the human resources crisis in the health sector of developing countries has only been attracting the attention it deserves for a few years (3, 4, 14). In previous years, many development cooperation organisations were reluctant to address this complex issue. However, significant improvements have been observed for about 15 years. After all, the issue was on the agenda of the annual World Health Assembly for three consecutive years. The Human Resources for Health overcoming the crisis – Joint Learning Initiative was founded in 2004 and has been working intensively on this topic ever since (2, 4). In 2005, the MDG Annual Conference and the European Union (EU) addressed the issue. The EU adopted a strategy on action to tackle the acute shortage of health workers in developing countries (14). A year later, the problem was the main topic of the World Health Report and the Decade of Action for Human Resources was proclaimed (1). All these initiatives focus on strengthening health systems. This involves long-term personnel planning, greater investment in training, the transfer of medical tasks to non-medical health personnel, the involvement of community-based health workers and strategies to prevent the brain drain.

In addition to these comprehensive initiatives to give the topic more importance, numerous individual activities are also worth mentioning, which could promise an improvement of the situation. WHO is currently working on an International Code of Practice on the migration of health workers, which will set standards for recruitment and employment (14). In some developing countries, legislation is now enforcing that health professionals work in rural areas for several years before receiving their diplomas. In Tanzania and Uganda, a new professional profile was created with the Assistant Medical Officer (AMO) (8). After three years of training as a Clinical Officer, the AMO has completed a two-year training course authorizing it to perform medical activities such as diagnosis, therapy planning and even surgical procedures. However, the AMO does not correspond to any European or North American professional profile, which makes emigration less likely. In some countries, attempts are being made to make transfer policy more transparent and to take more account of the wishes of staff. Among other things, the local staff shortage is met by meeting every transfer request to a rural area and the willingness to work in the countryside is recognised with additional wage payments (8).

Another approach is the German programme for returning experts of the Centre for International Migration. This programme supports the reintegration of some 700 highly qualified and returning workers – including health workers – into their home countries each year. As part of a programme sponsored by the German Academic Exchange Service, the Institute for Public Health at the University of Heidelberg offers seminars for medical students from developing and emerging countries who are studying at German universities. These seminars prepare future doctors for their return to their home countries.

Strengthening health systems, including the financing of human resources, is now at the top of the list of priorities for many developing countries, but also for their development cooperation partners (15). However, we are a long way from finding a solution in principle. Without a willingness to invest significantly more resources in improving basic health services, including education and training of health workers in developing countries, and without further innovative ideas to overcome the staff shortage, success is unlikely (4). Improving the situation also means that rich countries, which continue to thin out personnel in developing countries without great scruples, are putting their own interests on the back burner.


1. Organisation for Economic Cooperation and Development: International migration outlook. Sopemi, 2007 Edition, OECD.
2. Joint learning initiative human resources for health overcoming the crisis. Cambridge, MA: Harvard University Press 2004.
3. Narasimhan VN, Brown H, Pablos-Mendez A et al.: Responding to the global human resources crisis. The Lancet 2004; 363: 1469–72. MEDLINE
4. Chen L, Evans T, Anand S et al.: Human resources for health: overcoming the crisis. The Lancet 2004; 364: 1984–90. MEDLINE
5. The Millennium Development Goals Report: United Nations, Department of Economic and Social Affairs 2009.
6. Omaswa F: Human resources for global health: time for action is now. The Lancet 2008; 371: 625–6. MEDLINE
7. You D, Wardlaw T, Salama P, Jones G: Levels and trends in under-5 mortality, 1990–2008. The Lancet 2010; 375: 100–2. MEDLINE
8. Hongoro C, McPake B: How to bridge the gap in human resources for health. Lancet 2004; 364: 1451–6. MEDLINE
9. Lewis M: Informal payments and the financing of health care in developing and transition countries. Health Affairs 2007; 26: 984–97. MEDLINE
10. Stilwell B, Diallo K, Zurn P, Vujicic M, Adams O, Dal Poz M: Migration of health-care workers from developing countries: strategic approaches to its management. Bull WHO 2004; 82: 595–600.
11. WHO: Working together for health. World Health Report, Geneva 2006.
12. Dettmer S, Kuhlmey A, Scholz S: Karriere und Lebensplanung: Gehen oder bleiben? Dtsch Ärztebl 2010; 107(1–2): 26–7. VOLLTEXT
13. Mills EJ, Schabas WA, Volmink J et al.: Should active recruitment of health workers from sub-Saharan Africa be viewed as a crime? The Lancet 2008; 371: 685–8. MEDLINE
14. Europäisches Parlament: EU-Strategie über Maßnahmen zur Bekämpfung des akuten Fachkräftemangels im Gesundheitswesen der Entwicklungsländer. Brüssel: Kommission der Europäischen Gemeinschaften 2005.
15. WHO: Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva: WHO 2007.