July 20, 2010 — Global health workforce targets set by the World Health Organization are unrealistic for many low-income developing countries, according to an article in the July 2010 issue of Health Affairs by Harvard School of Public Health (HSPH) researchers Thomas Bossert and Tomoko Ono. They propose an alternative targeting mechanism that takes into account a country’s available financial resources and shifts the mix of health care workers to a more efficient, less costly mix of doctors, nurses and midwives.
In 2000, eight comprehensive Millennium Development Goals (MDGs) were adopted by the United Nations to tackle poverty and hunger; maternal and child mortality; disease; inadequate shelter; access to primary education; gender inequality; and environmental degradation. In addition, the Global Partnership for Development was created to ensure that global leaders are committed to good governance and development and poverty reduction by addressing the special needs of the least developed countries. Each goal is comprised of 21 quantifiable targets that are measured by 60 indicators and are catalysts for strengthening international collaboration to ensure that human development reaches everyone around the world by 2015.
In order to address the global health workforce shortage, a major barrier to achieving the MDGs, the World Health Organization (WHO) proposed a health worker target for all countries—a minimum of 2.3 health workers (physicians, nurses and midwives combined) per 1,000 people. Bossert, lecturer on global health policy in the Department of Global Health and Population and director of the International Health Systems Program at HSPH, and Ono, a doctoral student in the department, conclude that a universal benchmark is unrealistic for less developed countries that lack the financial resources to close this health worker shortage gap.
“If you look at how many health workers are required based on WHO’s minimal targets assessment, countries like Ethiopia and Tanzania would have to spend almost half their gross domestic product (GDP) on health care in order to finance that many health workers,” said Bossert, who has spent more than 20 years researching and investigating ways to effectively decentralize and reform health care systems in Latin America, Africa and Asia. “There are few countries that can afford to spend more than ten percent of their GDP on health.”
Unlike WHO and other organizations that use a “one size fits all approach” to target setting by implementing general targets, Bossert and Ono propose a simple target system based on the economic capacity of an individual country. They believe 10 percent of GDP devoted to health care costs is a reasonable figure. Their approach involves a combination of gathering data about each country’s GDP and government budget. They also propose modifying the mix of health care providers to reduce health care costs, for example, by increasing the ratio of nurses and midwives to doctors.
Although the article acknowledges that general target setting can be useful in global public health because targets are easy to understand and they help people prioritize certain types of problems, Bossert suggests they pose limitations when a country fails to reach its projected target.
“I find that governments set public health targets or goals arbitrarily and they are very unrealistic for poor countries, in Africa especially,” said Bossert. “Our research is aimed at creating more appropriate targets so ministries of finance and other donors will see them as having a realistic chance to be met.”
“We hope these targets can be used as the basis for a more detailed labor market analysis in each country,” added Ono.
“Finding Affordable Health Workforce Targets in Low-Income Nations,” Thomas J. Bossert, Tomoko Ono, Health Affairs, July 2010.