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Global problems of recruitment and retention

Challenges with the recruitment and retention of doctors are not just something facing Ireland, a major international conference in Dublin recently heard.

The Fourth Global Forum on Human Resources for Health saw over 1,000 international delegates attend a series of meetings and discussions over four days in the RDS, Dublin. Delegates heard that the world is facing an estimated shortfall of up to 18 million health workers by 2030, primarily in low and lower-middle income countries, while in the European region, there is an estimated potential shortfall of around one million health workers by 2020.

In his welcome note to delegates written in the ‘Forum Programme’, Minister for Health Simon Harris noted that as “in many parts of the world, the health sector in Ireland is experiencing challenges in the recruitment and retention of health professionals, including doctors and nurses”.

At the Forum Minister Harris launched the new National Strategic Framework for Health and Social Care Workforce Planning, which he said was created by a cross-sectoral steering group that would implement a five-point plan. “The objective of the Framework is to identify, agree and implement appropriate solutions to health workforce challenges – either within the health sector or inter-sectorally with education and other partners,” said Minister Harris.

Planning

Speaking at the Forum, Ms Gabrielle Jacob from the Department of Health outlined the slow building process it took to create the national strategy. When asked what were the difficulties with formulating such a cross-sectoral plan on health workforce planning, she said different departments have different concerns. “At a national level every ministry has its own imperatives… [But] somewhere within that you have to carve out a space where you have an agreed shared objective.”

Irish man Dr Mike Ryan, who is a member of the World Health Organisation (WHO) Advisory Group on the Ebola Virus Disease Response, spoke about his international experience in public health.

He said there was often too much “systems think” in public health. “I think sometimes we take an engineering analysis to the health system,” he said in remarks that were well received by delegates. “We try and break the health system down into a load of boxes and a load of lines. It all looks great, but the health system is very organic. It exists in the context of economic crisis, conflict and issues of broader governance. It has got to be resilient; it has got to be adaptive. The strategy itself has to be adaptable and resilient.”

Courage

Dr Ryan also noted “all systems punish the whistle-blower”.

“Whatever we might say, it does. Those who speak out and identify issues are quickly ground down by the system, because they are actually threatening the system. We have got to change the mind-set so that surfacing the issues is the most important thing that needs to happen.”

Dr Ryan added that the “single biggest missing ingredient in public health policy at all levels of the system, including at a global health level, is courage”.  

However, reflecting on his experience with Ebola and the WHO polio eradication programme, he said, “we need to reflect on the real heroes. When I said we need courage, I forgot to put a caveat in. The real heroes are the really courageous, they are the frontline health workers”.

He paid tribute to nurses and doctors who had died in Uganda and Pakistan in recent years and currently in Yemen where “there are thousands of health workers working unpaid, with their health facilities actively under attack”.

“We owe those frontline workers our loyalty…. Human resources for health is not just about policy makers. We should refocus on what we want to achieve and measure [progress].”

The Forum committed to improving the safety and security of health workers by upholding international humanitarian law, strongly condemning violence, attacks and threats directed against medical personnel and facilities.

Ireland

At a national level, the Global Forum also heard new research from the RCSI Health Workforce Research Group on inward and outward migration of doctors from Ireland.

Among its findings, the RCSI research found that between 6 and 9 per cent of doctors between 25 and 44 years of age exit the Medical Council register annually, with highest rates among foreign doctors and lowest rates among Irish graduates. Exits from the general division of the Medical Council register, where most non-EU graduates are registered, are three times higher than exits from the specialist register. The increasing reliance on non-training posts is partly driven by the European Working Time Directive (EWTD), but also by a failure to expand and fill consultant posts, the head of the RCSI Group Prof Ruairi Brugha told the Forum.

He also cited unpublished data from a 2016 survey, which showed that 20 per cent of trainees left Ireland between 2014, when they were first surveyed, and 2016 when they were surveyed again.

According to the RCSI Group, the body of evidence from recent publications points to the same constellation of factors that push trainees to leave Ireland: Stressful working conditions (notably, having to undertake non-core tasks); lack of protected and supervised training, which gets displaced by service demands; and unclear and unattractive career opportunities.

Transform

Speaking via video link to the opening of the Global Forum, the WHO Director General called for political and financial commitment to expand and transform the global health workforce.

“This is not a cost. It is an investment. An investment that should be nurtured,” said Dr Tedros Adhanom Ghebreyesus.

“The fact is, investing in health workers creates jobs, drives growth and increases productivity by getting sick people out of care and back to work.”

At its conclusion, the Forum unanimously adopted the Dublin Declaration, a multisectoral and multi-stakeholder declaration for improved governance, strategic investments and financing for a sustainable health workforce and to ensure countries move with greater speed to the goal of universal health coverage.

The commitments include making investments towards transformative health workforce education and job creation.

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